case_images: PMC10864105_01
case_images: First case: Eighteen-month-old girl with cloaca. (
  A
  ) Contrast X-ray study demonstrating the rectum (R), vagina (V), and common channel (CC). Computed tomography (CT) scan of abdomen and pelvis following contrast injection in vagina and rectum: sagittal, axial, coronal, and three-dimensional (3D) reconstruction (
  B
  -
  E
  , respectively). Urinary bladder (UB); hemi-vagina (V); rectum (R); first sacral vertebra (*). Note: the presence of longitudinal vaginal septum between 2 hemi-vaginas (
  C
  and
  E
  ); hydronephrotic right kidney (long black arrow in
  D
  ), and ectopic (low position) left kidney (short black arrow in
  D
  ).
case_images: 10-1055-a-2204-8629-i2023080729cr-1.jpg
case_images: PMC10864105_01_10-1055-a-2204-8629-i2023080729cr-1.jpg
case_images: FI2023080729cr-1
case_images: Associated anomalies included right hydroureteronephrosis, ectopic (low position) left kidney, and longitudinal vaginal septum ( Fig. 1 ).
case_images: Second case: Seven-month-old girl with cloaca. (
  A
  ) Contrast X-ray study demonstrating the rectum (R) and vagina (V). (
  B
  and
  C
  ) Pelvic magnetic resonance imaging (MRI) (sagittal T2-weighted image [T2WI]) demonstrating urinary bladder (UB), vagina (v), rectum (R), pubis (P), and first sacral vertebra (*). Note the presence of tube in the vagina (vaginostomy tube).
case_images: 10-1055-a-2204-8629-i2023080729cr-2.jpg
case_images: PMC10864105_01_10-1055-a-2204-8629-i2023080729cr-2.jpg
case_images: FI2023080729cr-2
case_images:  Case 2: The second case had a pelvic colostomy performed at birth in addition to tube vaginostomy (via a self-retaining Foley's catheter) for associated hydrocolpos ( Fig. 2 ).
case_images: Third case: Six-month-old girl with cloaca. (
  A
  ) Contrast X-ray study (genitogram) demonstrating two hemi-vaginas (V). (
  B
  ) Pelvic magnetic resonance imaging (MRI) (sagittal T2-weighted image [T2WI]) demonstrating urinary bladder (UB), vagina (v), rectum (R), pubis (P), and common channel (cc). (
  C
  and
  D
  ) Three-dimensional (3D) MR urography (coronal and sagittal, respectively) demonstrating bilateral hydroureteronephrosis, distended two hemi-vaginas (V), and distended urinary bladder (UB).
case_images: 10-1055-a-2204-8629-i2023080729cr-3.jpg
case_images: PMC10864105_01_10-1055-a-2204-8629-i2023080729cr-3.jpg
case_images: FI2023080729cr-3
case_images: Preoperative imaging demonstrated bilateral hydroureteronephrosis in addition to markedly distended two hemi-vaginas ( Fig. 3 ).
case_images: Operative steps of posterior sagittal anorectoplasty (PSARP). (
  A
  ) The patient is positioned in prone position. (
  B
  ) Midline posterior sagittal incision. (
  C
  ) The levator ani is incised in the midline to reach the rectum above. (
  D
  ) The rectum (R) is mobilized by dissection of perirectal fascia. (
  E
  ) A vertical midline incision is made in the posterior wall of the mobilized distal rectum to expose its fistulous communication anteriorly into the vagina/sinus.
case_images: 10-1055-a-2204-8629-i2023080729cr-4.jpg
case_images: PMC10864105_01_10-1055-a-2204-8629-i2023080729cr-4.jpg
case_images: FI2023080729cr-4
case_images: Anorectoplasty (PSARP), excision of vaginal septum, and posterior sinuplasty were performed with uneventful postoperative recovery ( Figs. 4 5 6 7 ).
case_images: Operative steps of posterior sinuplasty. (
  A
  ) Separation of the rectum (R) from the vagina to be followed by excision of longitudinal septum (white arrow). (
  B
  ) A vertical incision (broken arrow) is made through the posterior wall of the common urogenital sinus toward but not reaching the perineum. (
  C
  ) This vertical defect is then closed horizontally displacing the posterior vaginal wall (V) downwards toward the perineum.
case_images: 10-1055-a-2204-8629-i2023080729cr-5.jpg
case_images: PMC10864105_01_10-1055-a-2204-8629-i2023080729cr-5.jpg
case_images: FI2023080729cr-5
case_images: Anorectoplasty (PSARP), excision of vaginal septum, and posterior sinuplasty were performed with uneventful postoperative recovery ( Figs. 4 5 6 7 ).
case_images: Diagram illustrating posterior sinuplasty. (
  A
  ) A case of cloaca: Urinary bladder (UB). Urethra, vagina (V), and rectum (R) join into a common channel (CC). (
  B
  ) After separation of the rectum (R), a vertical incision is made in the posterior wall of the common channel (broken blue line). (
  C
  ) The posterior vaginal wall (red line) is displaced downwards to close the posterior defect in the common channel.
case_images: 10-1055-a-2204-8629-i2023080729cr-6.jpg
case_images: PMC10864105_01_10-1055-a-2204-8629-i2023080729cr-6.jpg
case_images: FI2023080729cr-6
case_images: Anorectoplasty (PSARP), excision of vaginal septum, and posterior sinuplasty were performed with uneventful postoperative recovery ( Figs. 4 5 6 7 ).
case_images: Operative steps of posterior sagittal anorectoplasty (PSARP) (continued). (
  A
  ) The pelvic floor and striated sphincter muscles are reconstructed around the neo-anus and rectum. (
  B
  ) The anocutaneous anastomosis is performed at the predestined site of the normal anus. (
  C
  ) Follow-up after 2 weeks.
case_images: 10-1055-a-2204-8629-i2023080729cr-7.jpg
case_images: PMC10864105_01_10-1055-a-2204-8629-i2023080729cr-7.jpg
case_images: FI2023080729cr-7
case_images: Anorectoplasty (PSARP), excision of vaginal septum, and posterior sinuplasty were performed with uneventful postoperative recovery ( Figs. 4 5 6 7 ).
case_images: Pelvic magnetic resonance imaging (MRI) (axial T2-weighted image [T2WI]) of the third case comparing vaginal distension before (
  A
  ) and after operation (
  B
  ). Urinary bladder (UB), vagina (V), and rectum (R). Note vaginal collapse in (
  B
  ) after posterior sinuplasty and excision of longitudinal septum.
case_images: 10-1055-a-2204-8629-i2023080729cr-8.jpg
case_images: PMC10864105_01_10-1055-a-2204-8629-i2023080729cr-8.jpg
case_images: FI2023080729cr-8
case_images: Postoperative pelvic MRI (3 months later) confirmed adequate drainage of hydrocolpos ( Fig. 8 ) and good location of neorectum within muscle complex.