aroscopy or laparotomy (Figure 6).
◦ Imperforate anus without fistula
In patients with imperforate anus without fistula, the same meticulous dissection is required to separate the distal rectum from the urinary tract as in patient with rectourinary fistulae because the rectum and urethra still share a common wall.
◦ Rectovestibular fistula
In cases of rectovestibular fistula, the posterior sagittal incision can be shorter than in male patients with rectourethral fistulae. Often the entire levator mechanism needs not be divided and only the external sphincter, muscle complex, and part of the lower portion of the levator mechanism need to be divided. The rectum and posterior vagina share a common wall, and it is this separation that is the most difficult part of the operation. Once the rectum is completely mobilized, a perineal body is constructed, and the rectum is placed within the limits of the sphincter mechanism .
◦ Rectal atresia
A very rare malformation, rectal atresia, occurs in 1% of cases. The anal canal is normal and externally the anus appear normal. However, there is a blockage 1–2 cm from the anal skin, usually found when the nurse tries to pass a thermometer. These babies should undergo colostomy at birth, and then their definitive repair involves a posterior sagittal approach and an end-to-end anastomosis between the upper rectal pouch and the anal canal.
◦ Persistent cloacas
The repair of persistent cloacas represents a serious technical challenge that should be performed in specialized centers by pediatric surgeons dedicated to the care of these complicated patients . This malformation represents a wide spectrum of defects by itself. The defect involves fusion of the rectum, vagina, and urethra together to form a common channel (Figure 7). The length of this common channel can range from 1 to 10 cm. The rectum and vagina share a common wall and the vagina and urinary tract likewise have a common wall. The goals of surgical treatment are to achieve bowel control, urinary control, and normal sexual function. Sometimes all three goals are achieved, sometimes only two, often only one, and occasionally none .
Prognostic factors include the quality of the sacrum, the quality of the muscles, and the length of the common channel. We have arbitrarily defined two groups of patients. The repair of patients with a common channel less than three cm is reproducible and is feasible for most pediatric surgeons. For patients with a common channel greater than three cm, the repair should be performed at a specialized center by a surgeon with experience managing the urologic anomalies and able to performing complex vaginal reconstructions. If the common channel is less than 3 cm, the posterior sagittal approach without an abdominal approach can be used to repair the defect.
For patients with a common channel greater than three cm, a laparotomy is usually required. Often the vagina and urinary tract must be separated trying to gain length, and the urethra must then be reconstructed. The surgeon must be prepared to open the bladder and to reimplant the ureters if necessary. Complex vaginal mobilizations are often required and frequenly a vaginal replacement with small intestine or colon is necessary. The pullthrough of the rectum is similar to other anorectal malformations. It is the repair of the vagina, the urethra, and the associated urologic defects that represents the main surgical challenge. A large vagina can be an advantage during the definitive repair because the surgeon can more easily mobilize it and has more alternatives for the vaginal repair. About 50% of patients have various degrees of vaginal or uterine septation. These can be totally or partially repaired during the main operation. The precise gynecologic anatomy must be ascertained either during the main repair or during colostomy closure (if a laparotomy was not required during the main repair). We have learned that approximately one third of our patients have obstructed Mullerian structures which can lead to severe problems resulting from retrograde menst