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Robotic Repair of High Common Urogenital Sinus at Puberty
Natalie Leva, MD, Yi Li, MD, Sunghoon KIm, MD, Laurence Baskin, MD.
UCSF, San Francisco, CA, USA.

BACKGROUND: We describe a case of high urogenital sinus managed by XI robotic assisted laparoscopic reconstruction in an 11-year-old female with congenital adrenal hyperplasia.
CASE PRESENTATION: The patient presented at one year of age with mild penile torsion (Figure 1) and bilateral non palpable testes. Workup revealed a XX karyotype and non-salt losing 21 hydroxylase deficiency with a high common urogenital sinus. At 14 months of age a feminizing genitoplasty was performed without reconstruction of the urogenital sinus secondary to the high confluence. At 11 years of age the patient began menarche with monthly menstruation through the common urogenital channel. EUA and 3D radiographic reconstruction demonstrated the high confluence just below the bladder neck with a dilated vagina (Figure 2). The patient underwent XI robotic assisted laparoscopic reconstruction of the high urogenital by separation of the vagina from the high confluence of the common urogenital sinus. Key steps in the procedure are placement of JJ stents to clearly define ureteral insertion into the bladder, placement of stents in the vagina and bladder, defining the plane between the bladder and anterior vagina by staying in the midline, placing hitch stitches in the posterior bladder wall and proximal vagina for visualization of the confluence thereby facilitating dissection (Figure 3), defining the high urogenital confluence, separating the confluence from vagina (Figure 4), suturing the fistula at the confluence so the common urogenital channel becomes the urethra, opening up the narrow distal vagina, and placing a 11 step port through the perineum to facilitate the vaginal pull thorough (Figure 5). We have a video presentation of the of the robotic repair emphasizing these key robotic surgical steps.
CONCLUSIONS: Reconstruction of the High Common Urogenital Sinus at Puberty is facilitated by a robotic approach which allows excellent visualization and dissection in the pelvis.





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