Robotic-assisted repair of a rare cloacal anomaly
Michael R. Phillips, MD, Charles Vinocur, MD, Jennifer Hagerty, DO.
Nemours/Alfred I. DuPont Hospital for Children, Wilmington, DE, USA.
BACKGROUND: Urogenital sinus (US) and an anorectal malformation (ARM) is an uncommon cloacal anomaly. The optimal surgical approach is unclear. Others have described a combination of abdominal and perineal approaches, with additional studies examining robotic approaches for isolated vaginal anomalies in adolescent patients. METHODS/RESULTS: A 20-month old Amish female presented to the emergency room with fever and abdominal pain. Abdominal ultrasound showed a large fluid filled vagina, urinalysis was positive, and she was admitted for antibiotic therapy. MRI confirmed a dilated vagina and right hydronephrosis. An examination under anesthesia in the operating room including cystoscopy demonstrated a short perineal body, an anteriorly displaced anus by muscle stimulation, and no vaginal opening. Ultrasound guided, percutaneous vaginostomy tube was placed, and 650 cc of pus was drained. Vaginal and urine cultures grew 4+ E. coli. Following a course of antibiotics, she underwent a robotic-assisted mobilization of the intra-abdominal vagina and uterus, posterior sagittal anorectoplasty (PSARP), vaginal pull-through, and a diverting colostomy. There were no intra-operative complications. A regular diet was started on post-op day #1. Her foley was removed on POD #3, she voided spontaneously and was discharged in good condition. She remained in the hospital for ostomy teaching, but pain control and diet were not barriers to discharge after 12 hours.
CONCLUSIONS: Robotic mobilization of the intra-abdominal vagina in a pediatric patient is technically feasible and can be accomplished safely. Further comparative studies to other approaches are lacking. In this case the robot allowed for good visualization, intra-operative collaboration between multiple specialties for complex patients with aberrant anatomy, and easy dissection in a narrow pre-pubertal pelvis and would be an approach that our group employs in future cases. 
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