We describe our experience with laparoscopic urogenital separation and laparoscopic vaginal and rectal pullthrough in patients with cloacal malformation.

Five patients were operated over a period of 2.5 yrs December 2017 – February 2020, they carried out laparoscopic total urogenital separation and rectal pull through.

Five female patients born with single perineal opening had colostomy at birth. Age during the second operation ranged from 1.5-2.5 years. Common channel ranged between 1.5 cm and 5cm.
Preoperative investigations included genitogram for all patients, MRI  pelvis in 3 patients, abdominal US was available in 3 patients ‚ in 2 patients the urethral length was noted and recorded in patients note.
Average operative time was 5 hours.
Post operative period was 1 day to 5 days and uneventful.
4 patients were able to micturate spontaneously upon removal of the urinary catheter, one patient had urine retentions upon removal of the catheter managed with intermittent urinary catheterisation and gradually improving. In the one year follow up 
No patient developed urethro vaginal fistula and two patients developed vaginal stenosis. All patients had no urinary problems.
All Patients had reversal of stoma.

It has been suggested that it is the urethral Length rather than length of the common channel that influence the choice of operation, (1) It is also recommended that Total urogenital mobilisation(TUM) should be avoided in patients with short urethra as intraoperative decision to shift to urogenital separation will risk devascularisation of the urethra.(1)

In literature before the significance of urethral length was highlighted, total urogenital mobilisation was recommended for patients with common channel less that 3 cm and for those >3cm TUM was followed by urogenital separation.(1)

Total urogenital mobilisation was originally fashioned to overcome the technical difficulty of separating the vaginal from the bladder wall.

On the other hand‚ Urogenital separation will preserve the urogenital sinus(common channel) by disconnecting the vagina (fig 1a,b) from the urogenital sinus and saving it for the urethra and joining the vagina to the perineum by the same technique recently described for laparoscopic vaginal pullthrough in patients having congenital hyperplasia. (2) We believe the application of this technique to patients with cloaca is more feasible as there is no debate as regard age of intervention as in patients with congenital adrenal hyperplasia.  By preserving the urogenital sinus for the urethra we therefore preserve the continence since continence requires having a bladder with satisfactory capacity and normal intra vesical pressure, together with sufficient outlet resistance to prevent leakage at normal activity.

The separation of the vagina from the common channel is reminiscent of the original cloacal repair in which the vagina was always separated by Dr.Hardy Hendren.(3)

Laparoscopic Urogenital separation, vaginal and rectal pullthrough for cloacal malformation is feasible in cloacal malformation and efficient especially due to improved visualisation of the pelvic anatomy, provide good access for the mobilisation and dissection of the vagina and rectal fistula and separation from urological system, inaddition to the better cosmetic appearance of the perineum(fig2a,b)

Wood RJ, Reck-Burneo CA, Dajusta D, Ching C, Jayanthi R, Bates DG, Fuchs ME, McCracken K, Hewitt G, Levitt MA. Cloaca reconstruction: a new algorithm which considers the role of urethral length in determining surgical planning. J Pediatr Surg. 2017 Oct 12:S0022-3468(17)30644-9. doi: 10.1016/j.jpedsurg.2017.10.022. Epub ahead of print. Erratum in: J Pediatr Surg. 2018 Mar;53(3):582-583. PMID: 29132797.
Marei MM, Fares AE, Abdelsattar AH, Abdullateef KS, Seif H, Hassan MM, Elkotby M, Eltagy G, Elbarbary MM. Anatomical measurements of the urogenital sinus in virilized female children due to congenital adrenal hyperplasia. J Pediatr Urol. 2016 Oct;12(5):282.e1-282.e8. doi: 10.1016/j.jpurol.2016.02.008. Epub 2016 Mar 2. PMID: 26994589.
W. Hardy Hendren, Further experience in reconstructive surgery for cloacal anomalies, Journal of Pediatric Surgery, Volume 17, Issue 6, 1982, Pages 695-717, ISSN 0022-3468, https://doi.org/10.1016/S0022-3468(82)80434-X.