EP246 - Sphincteroplasty with perineal body reconstruction for cloaca-like deformity caused by fourth-degree perineal laceration

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Purpose/Background: Third- and fourth-degree perineal lacerations complicate approximately with 1.4% of all vaginal delivery in Japan. In some rare cases of fourth-degree lacerations, complete disruption of the sphincter muscles, rectal mucosa and perineal body can occur, resulting in a cloaca-like deformity. This deformity is characterized by dehiscence of the rectovaginal septum and the absence of epidermal tissue between the rectal and vaginal mucosa, leading to a three-dimensional defect at perineum. Patients with cloaca-like deformity suffer from fecal incontinence and significant cosmetic concerns, severely affecting their quality of life. Although surgical repair is the primary treatment, simple sphincteroplasty may not suffice and simultaneous perineal body reconstruction is critical to acquire optimal function and aesthetic outcomes. This study presents our clinical experience of sphincteroplasty combined with simultaneous perineal body reconstruction with cloaca-like deformity secondary to obstetric trauma.

Methods/Interventions: From January 2021 to December 2023, four female patients (mean age: 38 years) with cloaca-like deformity following obstetric fourth-degree perineal laceration underwent sphincteroplasty with simultaneous perineal body reconstruction. All patients were provided written informed consent. The following standardized surgical procedure was used: With the patient in the prone jackknife position, a transverse incision at the fused anoderm-vaginal wall was made and the posterior vaginal wall and the anterior anorectal wall were then separated to reconstruct the rectovaginal septum. After identifying and mobilizing the torn ends of the sphincter muscle and the perineal body, overlapping sutures were used to repair the sphincter, while the perineal body was reconstructed in three to four layers. Once the perineal body is fully reconstructed, transverse incision made at beginning of the procedure was converted to longitudinal wound, and offered good appearance of the perineum after wound closure.

Results/Outcomes: The mean operative time was 95 ± 18 min. No major perioperative complications were observed. After a median follow up of 20 months (range 12-41 months), all patients achieved complete resolution of fecal incontinence and were satisfied with their perineal appearance. Significant improvements were observed in anal resting pressure (43.7 ± 7.1 mmHg to 68.7 ± 8.9 mmHg), maximum anal systolic pressure (87.7 ± 35.6 mmHg to 128.8 ± 19.2 mmHg) and the Cleveland Clinic Fecal Incontinence score (12.8 ± 3.6 to 1.25 ± 1.5).

Conclusion/Discussion: Sphincteroplasty combined with perineal body reconstruction resulted in excellent functional and aesthetic outcomes in patients with cloaca-like deformity caused by fourth degree perineal laceration. This combined approach may be critical in managing such complex cases to restore both continence and perineal anatomy.