Total urogenital mobilization via prone approach

Abstract

Objective: A urogenital sinus (UGS) is a rare congenital condition defined by a common channel into which both the urinary and genital tracts drain. This malformation is often associated with other anomalies such as differences of sexual differentiation and cloacal malformations. One of the most popular techniques for repair is a Total Urogenital Mobilization (TUM), which involves circumferential mobilization of the sinus up behind the pubic bone. The Partial Urogenital Mobilization (PUM) is a modification of this technique that stops prior to dividing the pubourethral ligament and reaching the retropubic space. Here we aim to demonstrate the key steps of a full TUM in a UGS. Patients and surgical procedure: In this video, we present a 2-month-old female with a prenatally diagnosed posterior cloaca undergoing TUM. Preoperative vaginoscopy demonstrated a 3 cm common channel. We focus on the key steps of a TUM via a prone approach. Results: Key steps in such a case are 1) evaluation of the common channel 2) circumferential mobilization of the UGS 3) division of the suspensory ligament of the urethra (ie pubourethral ligament) 4) posterior division of the common channel to the vaginal confluence 5) anterior division of the common channel to near the level of the urethral meatus 6) fixation of the urethra to the labia majora and creation of the labia minora using the common channel flaps 7) fixation of the lateral vagina 8) recreation of the perineal body. Conclusion: TUM is an approach that can be employed in several congenital anomalies, most commonly UGS and cloacal anomalies. It involves circumferential dissection of the entire sinus up behind the pubis to allow for advancement down to the perineum with good cosmesis and outcomes. PUM can also be considered if adequate advancement is achieved prior to dividing the pubourethral ligament.