Recto-vagino-vestibuloplasty using a vagino-colonic flap with double colonic implantation for rectocloacal fistula

Abstract

This technique was devised to obtain a good cosmetic appearance of the perineum and a functional neovagina, without any need for a dilator, by using a vaginocolonic flap marsupialized to the perineum and by creating a vestibule with noncornifying squamous epithelium. The technique was used to treat a 2 year old girl who had a single small orifice in the upper part of a featureless perineum, with a high-confluence rectocloacal fistula between a short urethra and double vagina, which was separated by a septum. A long inverted U-shaped flap at the posterior wall of the vagina was reversed to become the anterior wall of the distal vagina. The urogenital sinus (UGS) was preserved to serve as the urethra. The colon distal to the colostomy was divided into two loops; a segment of the distal loop was opened and trimmed to form a flap, and served as the posterior wall of the distal vagina. The proximal segment was pulled down to become the rectum. To construct the vestibule, a vertical midline incision was made from the fused labia minora to the perineum, cutting back the UGS. The anterior wall of the vagina, which was pulled through just behind the UGS, was divided vertically and sutured around the opened UGS and the suitably prepared labia minora. The posterior wall, which consisted of the colonic flap, was sutured to the incised perineal skin, creating a posterior commissure. At present, 2 1 2 years after the repair, the patient is dry between completely continent urinations and has little vaginal discharge. A dilator has not been necessary, and the appearance of the perineum is almost normal.