Novel Use of AlloDerm for Vaginoplasty in Complex Cloaca Repair

Research study background

A multidisciplinary team of specialists from the International Center for Colorectal and Urogenital Care and the Department of Pediatric and Adolescent Gynecology at Children’s Hospital Colorado recently published their novel approach to vaginal reconstruction in a patient with a complex cloacal anomaly. They are the first to report utilizing AlloDerm, an acellular cadaver tissue matrix that supports tissue regeneration, in this scenario.

A 17-month female infant presented to Children’s Colorado for surgical management of a long channel cloaca. She had a complicated medical and surgical history that included prenatal diagnosis of hydrocolpos and hydronephrosis, colostomy with mucus fistula and vesicostomy performed by her previous hospital on her first day of life. She also had bilateral pyelostomies and was diagnosed with stage 5 chronic kidney disease (CKD) secondary to a congenital renal anomaly.

This surgical case report describes the infant’s cloacal reconstruction via a posterior sagittal approach. The rectum was successfully separated from the vagina and the common channel was left as the urethra. The team created a single vaginal canal, but there was not enough native vaginal tissue to reach the perineum. Although vaginal replacement with sigmoid colon was considered, the surgical risks were too high given the child's complex condition and renal impairment.

“In some cloaca cases, we may be able to avoid a colonic vaginoplasty, which is surgically more complex,” says Andrea Bischoff, MD. “This means our patients can spend less time in the operating room and recover faster.”

The remaining options included delayed vaginoplasty or using alternative grafts. Skin, amnion, buccal mucosa and acellular porcine tissues have been utilized for vaginoplasty in adolescents and adults with vaginal anomalies, but their application in cloacal reconstruction is very limited. Ultimately, the team opted for a vaginoplasty using AlloDerm. They used the grafts to form interior and posterior vaginal walls — marking the first known report of AlloDerm being used for vaginal replacement during cloacal reconstruction in a prepubertal child.

Twelve weeks after the cloacal repair, the surgical team closed the colostomy. They also performed a vaginoscopy, which showed an intact, 2 to 3 cm graft connected to the native vagina and a total vaginal length of 7 cm.

Clinical implications

This case highlights AlloDerm as a promising vaginal replacement option for patients with cloaca who are not suitable candidates for intestinal graft vaginoplasty. Initially developed for severe burns, AlloDerm’s use has broadened to include various plastic and reconstructive surgeries, with recent reports suggesting its safety and effectiveness in adult vaginal repair and reconstruction. While AlloDerm has higher surgical costs compared to autografts and lacks long-term outcomes data for this application, it avoids donor site morbidity which could potentially lower long-term costs. Further studies are needed to assess outcomes like vaginal stenosis, revision surgeries and patient satisfaction with AlloDerm vaginal grafts through puberty and adulthood.