Posterior Sagittal Anorectaplasty-Female Part III: Pediatric Colorectal...

Colon is preferred over small bowel for neovagina construction because small bowel mesentery is more tenuous and colon has more robust blood supply.

The neovagina serves three purposes: long-term sexual function, menstruation, and potentially conception if the cervix is competent.

7-8 centimeters is used for neovaginal conduit length based on normal vaginal length in an infant, though there is no science behind this measurement.

The family agreed to preserve structures that did not need removal, acknowledging uncertainty about future technology and outcomes.

Uterine transplantation has become successful within the past year, representing advancement in reproductive technology.

Neovagina should be tacked to pelvic fascia or posterior bladder to prevent prolapse and allow it to grow and lengthen into the pelvis.

Vaginal dilation is not performed post-operatively; a certain percentage will need introitoplasty later, but dilation is considered torture for patients.

Six months after breast budding, Müllerian structures must be monitored for dilation and menstrual function assessed.

Vaginoscopy should be performed after breast budding to determine if a cervix is present and if structures are larger.

If no cervix is found on vaginoscopy, there is a difficult decision between empirical removal of Müllerian structures or waiting for complications.

In patients without a cervix, some develop pelvic inflammatory disease episodes requiring removal, while others remain asymptomatic.

Anal transitional epithelium (dentate line) should be preserved during anoplasty rather than excised.

Pelvic MRI in infants struggles to identify vaginal lumen unless there is clearly hematocolpos or hydrocolpos; it is less helpful than desired.

MRI can frequently identify fallopian tubes, ovaries, and uterine anatomy, but determining the presence and characteristics of the vaginal lumen is very challenging with low confidence.

Keeping fluid in the vagina during MRI imaging is difficult once the patient is in the magnet.

No preoperative workup including independent examination under anesthesia, MRI, or better scoping would have changed the surgical approach in this case.

None of the imaging or office examination hinted at the Müllerian anatomy found intraoperatively; the office exam looked amazingly normal from a gynecologic point of view.

When the neovagina is connected to the patient's native vagina, it is already tethered into the abdomen and does not require additional tacking to the bladder.