Early Post-Operative Gynecologic Complications of Persistent Cloaca Reconstruction: A Single-Institution Review of 45 Cloacal Reconstructions.

STUDY

Objective

To determine whether cloacal complexity, defined by common channel length, is associated with early introital or vaginal stenosis following primary cloacal repair.

Methods

Retrospective analysis of a prospective cohort of patients with persistent cloaca treated at a quaternary-care children's hospital between January 2020 and May 2026. Patients who underwent primary cloacal repair with vaginal reconstruction and post-repair exam under anesthesia were included; those with cloacal exstrophy, cloacal variants, or prior repair at an outside institution were excluded. Complexity was defined by common channel length: moderate (<3 cm) or complex (≥3 cm). The primary outcome was any introital or vaginal stenosis at routine post-repair exam under anesthesia and vaginoscopy.

Results

Of 68 primary repairs, 45 patients were included: 27 (60.0%) had moderate cloaca and 18 (40.0%) had complex cloaca. The median age at repair was 0.7 years (range 0.4-10.1 years). Introital or vaginal stenosis occurred in 40.0% (18/45); 5 patients had complete stenosis, all of whom had complex cloaca. Stenosis was far more common following reconstruction of complex cloaca (72.2% vs. 18.5%; p<0.001), with 11-fold higher odds (OR 11.44, 95% CI 2.77-47.17), an association that persisted after adjusting for urethral length (OR 10.08, 95% CI 2.09-48.67; p=0.004). Each 1 cm increase in common channel length was associated with 2.50-fold higher odds of stenosis (95% CI 1.49-4.17; p<0.001), which persisted after adjusting for urethral length (p=0.002). The rate of stenosis was highest following urogenital separation (61.5%), compared with total urogenital mobilization (15.4%) and introitoplasty (0.0%) (p=0.002). Stenosis was also associated with older age at repair (1.0 vs. 0.6 years, p=0.015), uterovaginal anomalies (53.1% vs. 7.7%; p=0.005), longitudinal vaginal septum resection (56.5% vs. 22.7%, p=0.021), and longer operative time (440 vs. 284 minutes, p=0.0001).

Conclusions

Introital or vaginal stenosis was common (40.0%) in the early postoperative period following cloacal repair, and patients with complex cloaca had 11-fold higher odds of stenosis. These findings support anticipatory counseling and longitudinal gynecologic follow-up, particularly for patients with complex anatomy. IRB APPROVAL Children's National Hospital, IRB Pro00015991.