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

Why clinicians should know about it

• Picked for Pediatric Surgery (paper of the day, 9 October 2026): Retrospective cohort, cloacal repair outcomes

Abstract

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.

Abstract as published, via PubMed.