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Study Objective We investigated risk factors and common causes of tubo-ovarian abscess (TOA) in non−sexually active females in order to aid in earlier diagnosis, treatment, and improved outcomes. Design This is a retrospective observational case series of all non−sexually active females younger than age 25 years who were diagnosed with TOA. Review of the existing literature was also performed. Setting Academic tertiary care children's hospital. Participants Ten patients meeting study inclusion criteria were identified for the study, and 33 other patients were identified in the literature. Results Average age at time of diagnosis was 14 years. Average body mass index was 24 kg/m2. Most presented with abdominal pain, often associated with fevers, nausea, vomiting, and diarrhea. Seven of 10 patients were treated surgically with pelvic washout (4 primarily and 3 after failing empiric antibiotic therapy). Most frequently, anaerobic gut flora were isolated on culture. All patients received broad-spectrum intravenous antibiotics, and were then discharged on a course of doxycycline and metronidazole or clindamycin. Three patients required additional admissions and multiple rounds of antibiotics due to persistent symptoms. The average length of stay was 3 days for patients treated with antibiotics only and 6 days for patients requiring surgical intervention. Six patients had complete resolution of symptoms and improvement on ultrasound within 2-4 weeks. The remainder were lost to follow-up. Conclusion These cases, in conjunction with previous case reports, emphasize the importance of considering TOA in patients with concerning imaging or examination findings despite lack of sexual activity. Given the large proportion of cases attributable to anaerobic gut flora, treatment with antibiotics with adequate anaerobic coverage is recommended. Surgical drainage is not always necessary, but is often needed for diagnostic purposes or in patients not clinically improving with conservative measures.

Importance Many adolescents and young adults diagnosed with Hodgkin lymphoma (HL) experience disease progression requiring high-dose alkylating salvage therapy, which often results in permanent infertility. Objective The aim of this report is to discuss fertility preservation options in female patients with consideration of chemotherapeutic agents in HL. Evidence acquisition An electronic literature review was performed utilizing a combination of the terms "Hodgkin lymphoma," "fertility preservation," "ovarian tissue cryopreservation," "oocyte cryopreservation," "embryo cryopreservation," and "gonadotropin-releasing hormone agonist." References and data from identified sources were searched and compiled to complete this review. Results Initial treatment of HL is often nonsterilizing; however, salvage therapy and conditioning for stem cell transplantation confer significant gonadotoxicity. Established fertility preservation options for pubertal females include embryo cryopreservation and oocyte cryopreservation. These options are contraindicated within 6 months of receipt of chemotherapy. Ovarian tissue cryopreservation is an option for patients who require salvage therapy within 6 months of first-line therapy. Conclusions Timing and choice of fertility preservation techniques depends on planned first-line chemotherapy and response to treatment. In patients initially treated with low-risk chemotherapy, it is reasonable to defer invasive fertility techniques until treatment failure; however, upfront fertility preservation should be considered in patients planning to undergo primary treatment with high-risk therapy.

Müllerian duct anomalies are rare in the general population, occurring in less than 3% of women, but much more prevalent in female patients with anorectal malformation, occurring in up to 30% of these patients. Unicornuate uterus with a rudimentary non-communicating horn is a congenital anomaly of Müllerian development which can be seen in isolation or in conjunction with other anomalies, with several case reports described in patients with VACTERL association. These anomalies may be asymptomatic until the patient develops dysmenorrhea or devastating obstetrical complications. We describe the successful surgical management of an obstructive Müllerian anomaly in a post-pubertal female patient with anorectal malformation.

Acquired urethrovaginal fistulae and urethral atresia are rare findings in pediatric patients, but have been described in adult patients related to trauma or iatrogenic injury. Little exists in the published literature to guide management of such conditions in children, but lessons learned from congenital causes can help. Herein we discuss the preoperative evaluation and management of a child with an acquired urethrovaginal fistula and urethral atresia likely related to in utero compression from an intrapelvic sacrococcygeal teratoma and provide several images detailing the complex anatomy.

Background: Approximately 7% of adolescent girls have reproductive tract anomalies. Anomalies associated with complete outflow track obstruction present with primary amenorrhea and cyclic abdominal pain. Some outflow tract obstructions may be associated with renal, anorectal, vertebral, cardiac, tracheoesophageal, and limb anomalies. Outflow tract obstructions may occur at varying anatomic locations – vaginal, cervical, or uterine, each requiring different surgical management. Methods: We present the preoperative evaluation and surgical management of three different gynecologic outflow tract obstructions. Results: Physical exam, ultrasound, and MRI were obtained for each patient. The first obstruction was a transverse vaginal septum, which was treated with transperineal resection to allow menstrual egress. The second obstruction was identified as distal vaginal atresia and managed with operative pull-through of her native vagina. The third obstruction was found to be cervico-vaginal atresia and required hysterectomy and salpingectomy with preservation of the ovaries. Conclusions: Preoperative examination of the perineum and imaging with accurate interpretation is crucial to identify subtle but important distinctions in diagnosis, which can result in markedly different interventions ranging from transperineal resection of a transverse vaginal septum, vaginal pull-through procedure, to hysterectomy. The location of the gynecologic outflow obstruction dictates the proper surgical treatment of these patients. Keywords: Mullerian obstruction, Adolescent, Anorectal malformation

The purpose of this review is to outline current pediatric fertility preservation options, and discuss ethical and financial considerations impacting this rapidly expanding field.With the improvement in treatment of pediatric malignancies and medical conditions that threaten fertility, survival rates are increasing. Therefore, minimizing long-term morbidities such as gonadal damage and infertility is of utmost importance. Impaired fertility not only has a significant negative impact on patient's quality of life; in women, gonadal damage puts patients at risk for premature menopause, and increased risk of cardiac, skeletal, and cognitive issues. Fortunately, fertility preservation options exist for both female and male prepubertal and pubertal patients, and discussion of such options with patients and their families prior to the initiation of therapy and/or before further deterioration of gonadal function is crucial. A multidisciplinary approach to fertility counseling, with attention to the patient's goals and cultural beliefs, is ideal.Although several national organizations support integrating a fertility consultation into routine care, fertility preservation is still underutilized. Continued research is needed to understand barriers for patients/families and reduce the number of missed opportunities for fertility preservation.

A subset of patients with cloacal malformations requires vaginal replacement during their primary reconstruction, increasing the surgical complexity. Identifying factors which predict the need for vaginal replacement would facilitate operative planning.We retrospectively reviewed patients who underwent primary cloacal reconstruction at our Center (2014-2018) and assessed the length of the common channel, urethra, and vagina. The presence of hydrocolpos at birth, Müllerian anomalies, sacral ratio, and tethered cord were also assessed between patients who did and did not require vaginal replacement.50 patients were identified. 17/50 patients (34%) underwent a total urogenital mobilization (TUM), and none required vaginal replacement. 33/50 (66%) patients underwent a urogenital separation. 19/33 (58%) required vaginal replacement. This group had a shorter vagina (4.2 cm vs 6.6 cm, p 0.01). There was no difference in urethral or common channel length, number of cervices, sacral ratio, presence of a vaginal septum, hydrocolpos, or tethered cord between those who did and those who did not require vaginal replacement.Urethral and common channel lengths were used to successfully determine the operative plan (TUM or urogenital separation) to reconstruct cloacal malformations. The need for urogenital separation and a shorter vaginal length were predictive of the need for vaginal replacement.Level IV.Case series with no comparison groups.

This chapter describes the surgical management of an ectopic pregnancy via laparoscopic procedure as performed by the following approaches: laparoscopic as against open abdominal surgery, whether it is a laparoscopic salpingectomy, where the entire fallopian tube is surgically removed, or laparoscopic salpingostomy, where the products of conception only are removed from the fallopian tube, merely by incising the fallopian tube and suctioning the material out, leaving the fallopian tube intact. The text includes an introduction that outlines the indications, risks, alternatives, essential steps, needed equipment, and variations in technique for the procedure(s) in question. This is followed by a template operative dictation, which provides the reader with an operative report, such as is found in a patient chart or electronic medical record. A description is provided of the following critical concepts for this procedure: abdominal access, anatomic assessment, salpingostomy or salpingectomy, removal of ectopic pregnancy.

This chapter describes the surgical procedure for incision and drainage of Bartholin gland duct cyst or abscess as performed by open approach. The text includes an introduction that outlines the indications, risks, alternatives, essential steps, needed equipment, and variations in technique for the procedure in question. This is followed by a template operative dictation, which provides the reader with an operative report, such as is found in a patient chart or electronic medical record. A description is provided of the following critical concepts for this procedure: bimanual examination, vertical incision, placement of Word catheter, or marsupialization.

This chapter describes the surgical and nonsurgical management of ovarian, isolated fallopian tube, or adnexal torsion, via open and laparoscopic approach. The text includes an introduction that outlines the indications, risks, alternatives, essential steps, and variations in technique for the procedure in question. This is followed by a template operative dictation, which provides the reader with an operative report, such as is found in a patient chart or electronic medical record. A description is provided of the following critical concepts for this procedure: abdominal access, anatomic assessment, reduction of torsion, ovarian or paratubal cystectomy, and suture pexy of the ligament as needed.

This chapter describes the endoscopic/surgical procedure for ovarian cystectomy for benign ovarian masses as performed by the following approaches: open and laparoscopic. The text includes an introduction that outlines the indications, risks, alternatives, essential steps, needed equipment, and variations in technique for the procedure in question. This is followed by a template operative dictation, which provides the reader with an operative report, such as is found in a patient chart or electronic medical record. A description is provided of the following critical concepts for this procedure: positioning, abdominal access, identification and dissection of ovarian lesion, resection and specimen delivery, and abdominal closure.

This chapter describes the endoscopic/surgical procedure for staging laparotomy and oophorectomy for malignancy. The text includes an introduction that outlines the indications, risks, alternatives, essential steps, needed equipment, and variations in technique for the procedure in question. This is followed by a template operative dictation, which provides the reader with an operative report, such as is found in a patient chart or electronic medical record. A description is provided of the following critical concepts for this procedure: laparotomy, collection of intraperitoneal fluid, anatomic assessment (omentum, peritoneum, reproductive organs, and nodal basins), and closure.

Background Intrauterine devices (IUDs) and the contraceptive implant are long acting reversible contraception (LARC) methods commonly used by adolescents. Gynecology visits and insertion of LARC devices can provoke anxiety and pain for adolescents. Research on non-pharmacological interventions for management of adolescent anxiety and pain and is lacking; we aimed to determine the impact of non-pharmacologic interventions on patient reported pain and anxiety during office LARC insertions. Methods Patients undergoing an office LARC insertion were eligible. After IRB approval, a systematic controlled trial was conducted; allocating patients to an intervention group (aromatherapy, Buzzy Bee device, aromatherapy + Buzzy Bee device, nursing bedside support) using an alternating sequence. Three outcome variables were analyzed: self-reported pain scores and responses to 2 survey questions (regarding perceived effectiveness of the intervention on pain and anxiety). Numeric data was summarized using medians/IQRs and categorical data as frequency/percent. Chi-squared tests were used to detect differences by group in categorical variables and Kruskal-Wallis tests in continuous variables. A linear mixed effects model determined pain score association with age, time, procedure, and intervention. Proportional odds ordinal regression models were used for survey questions (age, procedure, intervention as possible predictor variables). Results 58%) underwent IUD insertion. Intervention groups were roughly equal in size. After adjusting for age, procedure, and time, we found no evidence for an effect of intervention on pain scores [(χ]_3^2=1.7,p=0.64). Variability in pain scores was driven by time point and procedure. Nexplanon insertions had lower pain scores throughout compared to IUD insertions. There was little evidence of an effect of intervention on the pain effectiveness survey question (χ_3^2=4.1,p=0.25) or anxiety effectiveness survey question after controlling for age and procedure (χ_3^2=2.5,p=0.47). However, the effect of procedure was significant in both models (pain: p=0.01, anxiety: p=0.05). Conclusions IUD insertion was more painful than Nexplanon insertion regardless of age; this may impact preprocedural counseling. When controlling for age and procedure, pain scores did not differ among intervention groups. The value of bedside nursing support cannot be underestimated. Ongoing research regarding non-pharmacologic interventions is needed to help minimize patient anxiety/discomfort and increase acceptability of office gynecologic procedures.

Background Despite patients reporting a desire for reproductive health education, research has shown that myelomeningocele patients rarely receive information about sexual and reproductive health. Patients not only want general reproductive health education, they also want education about limitations that are specific to their level of disability. Prior research lacks a clear understanding of the specific reproductive and sexual health topics currently covered by providers. With this gap in knowledge, patients are left with inadequate reproductive health education. The objective of this study was to evaluate the existing reproductive health education and reproductive health needs among patients with myelomeningocele. Methods All English-speaking patients age 12 or older with a myelomeningocele clinic visit at a tertiary children's hospital between October 2019 and September 2020 were surveyed. Parents assisted with survey completion when necessary. The survey response rate was 54%. The survey asked patients which reproductive health topics had been covered by a medical provider during any of their clinic visits and patients were offered a referral to a reproductive healthcare provider (RHP). Results In total, 67 surveys were completed by patients of the myelomeningocele clinic. A majority of patients were female (58%) and white (83%), and the median age was 18.5 (Range: 12, 50). Menses were discussed at a rate of 85% in females. Few patients had discussions with a provider about their fertility (42%), sexuality (37%), risk of sexually transmitted infections (45%), or had an existing relationship with a RHP (54%). Differences by sex were observed in contraception conversations (54% for females and 25% of males, p for difference Conclusions Overall, patients in the myelomeningocele clinic have a reported low rate of education on basic sexual and reproductive healthcare topics. The lack of consistent sexual and reproductive healthcare education across the patients supports the need for providers to re-evaluate how and when these topics are being discussed with patients and families. Establishing care with an RHP should be standardized in this population and reproductive healthcare should be considered a part of comprehensive care in all patients, regardless of disabilities.

Background Obstructive anomalies at any level of the reproductive tract increase the risk of endometriosis. While endometriosis may improve after relieving the obstruction, persistent endometriosis has been reported. While not common, vaginal endometriosis may occur in adolescents. A case of vaginal endometriosis in an adolescent with history of imperforate hymen is presented. Case A 14-year-old, never sexually active, female presented to a tertiary pediatric and adolescent gynecology clinic with secondary amenorrhea. She reported one episode of vaginal bleeding 4 months prior to presentation and had noted a “bulge” at her introitus for 1 year prior to the bleeding episode. She sought gynecologic care for the secondary amenorrhea and was diagnosed with an imperforate hymen and hematocolpos (Figure 1). She underwent a hymenectomy – notable for 800mL of menstrual blood, a dilated single cervix, and normal appearing vaginal mucosa. Her post-operative course was uncomplicated. She had monthly menses without dysmenorrhea. Three months after the hymenectomy she complained of painless intermenstrual vaginal bleeding that occurred after bowel movements. She had a history of constipation. An external genital exam and bimanual exam were unremarkable. A speculum exam was significant for diffuse red friable lesions on the vaginal mucosa and cervix which appeared similar to endometriosis (Figure 2). Her hymenectomy site was well healed. Constipation treatment was initiated. She underwent an exam under anesthesia and biopsy of the vaginal lesions. Pathology confirmed endometriosis. Progestin only pills (POPs) were started for hormonal suppression. Resolution of the vaginal bleeding with bowel movements occurred, however she initially struggled with pill compliance and breakthrough bleeding with POPs. At her most recent visit, she was doing well with minimal breakthrough bleeding, no bleeding after bowel movements, and no dysmenorrhea. She continues to treat her constipation. Comments The risk of endometriosis with obstructive outflow tract anomalies is well known, however, painless vaginal bleeding is not the typical presentation of adolescent endometriosis. While providers must consider other etiologies of vaginal bleeding in the adolescent, endometriosis should be included in the differential – particularly in women with a history of an outflow tract obstruction. Medical management using hormonal suppression to reduce the risk of endometriosis proliferation is recommended for adolescents with endometriosis – thereby achieving the overall goals of therapy: minimizing pain symptoms and maximizing quality of life and future fertility.

Background Anorectal malformations (ARM) are congenital defects that affect up to 1 in 5,000 babies; females with ARM are at higher risk for Mullerian anomalies, which are often difficult to diagnose prior to puberty. The objective of this study was to evaluate compliance with the recommended 6 month post-thelarche screening PUS, correlation between suspected Mullerian anatomy and the screening PUS findings, and the likelihood of identifying other gynecologic findings at the time of screening PUS in patients with ARMs. Methods Our institution has 112 post-thelarche females with ARM. After IRB approval, we performed a retrospective chart review of this cohort's medical records for demographics, suspected Mullerian anatomy (identified by previous imaging, either an MRI or US, and/or intraoperative findings), whether a screening PUS was performed, the PUS findings, and subsequent gynecologic interventions. Patient characteristics were reported as frequencies and percentages for categorical variables and compared using the nonparametric chi-square test. A significance threshold of p Results Of the 112 patients reviewed, 80 (71.4%) patients received the recommended post-thelarche screening PUS with a compliance rate of 71.4% (p Conclusions Our overall compliance rate with the recommended post-thelarche screening PUS was high (71.4%), correlated well with suspected Mullerian anatomy (96.3%), and changed the clinical management of 9 (11%) of patients. A post-thelarche screening PUS is valuable in the ARM population to stratify the risk of menstrual outflow obstruction, define Mullerian anatomy unknown prior to puberty, and diagnose gynecology abnormalities that required medical or surgical intervention. A prospective controlled study is necessary to confirm these findings.

Background Chronic pelvic pain is a hallmark sign of endometriosis in adolescents and can persist in the form of musculoskeletal pain despite medical management. There is limited evidence to support that pelvic floor physical therapy (PT) is an effective intervention in treating chronic pelvic pain secondary to endometriosis in adolescents. The purpose of this case series is to describe the change in functional ability in adolescent females following pelvic floor PT management of chronic pelvic pain as part of a multidisciplinary approach. Case Participants included twenty adolescent females median age 16.5 years (IQR 3). Retrospectively, participants were included if they were referred to pelvic floor PT for chronic pelvic pain by Pediatric and Adolescent Gynecology between April 2018 and August 2019. All participants included had diagnostic laparoscopy performed with biopsy confirmed endometriosis. Fifteen participants had surgery before referral to PT and 5 participants had surgery after starting PT. The median duration of symptoms prior to referral to PT was 2 years (IQR 1.75). Pelvic floor PT included patient education, relaxation techniques to decrease pelvic floor muscle tone, manual therapy, breathing and postural retraining, and therapeutic exercise including pelvic floor muscle strengthening. Due to the adolescent age of the participants, all pelvic floor PT techniques were only performed externally. The Patient Specific Functional Scale (PSFS) assesses patient reported function and was utilized to determine functional improvements in participants referred to pelvic floor PT. The PSFS is a 0 to 10 point scale with 0 representing maximal disability and 10 representing no disability. Participants were able to self-report between one and three functional impairments with this outcome measure. In this case series, the PSFS score was represented as a percentage rather than a raw number to account for the variable number of impairments patients could report. Functional status was captured at initial evaluation and participants demonstrated a baseline score of 45.1% (IQR 16.66) on the PSFS. Functional status was captured throughout their course of PT care with the PSFS. Participants self-reported a clinically significant functional median improvement of 23.3% (IQR 41.66) over a median number of 12 visits (IQR 10.50) (p Comments Participants in this case series reported significant functional improvement on the PSFS over the course of pelvic floor PT. This case series suggests that PT may be a helpful treatment option in the multidisciplinary approach to improve patient function in adolescents with endometriosis. Additional prospective controlled trials are warranted to assess the benefits of PT in this population.

Background Most congenital anomalies of the female reproductive system involve the uterus. Undescended fallopian tubes and ovaries are rare congenital defects and infrequently reported. Cases are usually discovered secondary to ectopic pregnancies or infertility. Case We present a 13-year-old postmenarcheal female who presented initially with left upper quadrant pain. Since preoperative imaging including an MRI of the abdomen was inconclusive, she underwent a diagnostic laparoscopy. Intraoperatively she was found to have a mass resembling a torsed accessory spleen adherent to an undescended fallopian tube as well as a small ovoid ectopic ovarian tissue. In the pelvis she was found to have a rudimentary left uterine horn which was associated with a truncated fallopian tube that appeared autoamputated; an enlarged left ovary with a simple ovarian cyst was noted as well. On the right side, a normal ovary, fallopian tube, and unicornuate uterus were noted. Pathology confirmed the mass was an infarcted accessory spleen associated with a portion of the fimbriated fallopian tube with a paratubal cyst, as well as ovarian tissue with a cystic follicle. Postoperatively she has done well with complete resolution of her pain. Comments Mullerian and splenic anomalies are rare, and co-presentation is rarer. Ultimately, clinical symptoms should guide surgical treatment and diagnosis of these rare anomalies.

Background VACTERL association (as defined by 3 or more anomalies in any of the following systems: vertebral, anorectal, cardiac, trachea-esophageal, renal, or limb) is present in around a third of patients with anorectal malformations (ARM). In female ARM patients’ gynecologic anomalies are seen in conjunction with 1 in 5 rectovestibular and 1 in 20 rectoperineal fistulae. This study hypothesized that the presence of VACTERL association would predict an increased risk of gynecologic anomalies and this information will help to guide evaluation and management protocols. Methods This study is a cross-sectional, retrospective analysis from the prospectively-collected, multicenter registry of the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). Subjects with inflammatory bowel disease were not eligible for the PCPLC registry. The 316 female subjects with a perineal or vestibular fistula who were enrolled in the registry by January 14, 2020 were included in this study. The relationship of VACTERL association, ARM plus an anomaly in two or more VACTERL systems, with presence of a genital anomaly was evaluated with Fisher's exact test (Table 2). The relationship of each individual VACTERL system with presence of a genital anomaly was analogously assessed. P-values reported were based on a 2-sided alternative and considered significant when less than 0.05. Results 316 patients with rectoperineal (n=162, 51.3%) or rectovestibular (n=154, 48.7%) fistulae underwent VACTERL screening and gynecologic evaluation. 83 (26.3%) of patients with rectoperineal fistulae or rectovestibular fistulae had gynecologic anomalies. (Table 1). Among subjects with VACTERL association, 70.4% have a spine anomaly, 68.7% have a renal anomaly, and 70% have a cardiovascular anomaly. Genital anomalies were present in 40.9% vs. 17.9% of subjects with vs. without VACTERL association (p Conclusions Presence of VACTERL association in patients with rectoperineal or rectovestibular fistula correlates with an increased risk of gynecologic anomalies and should prompt early involvement of pediatric gynecology in their care.

Gynecologic pain affects a significant number of adolescents. While the differential diagnosis for such pain is often extensive, the treatment goals are the same—to relieve pain and minimize the effect it has on an adolescent’s daily functioning, and to maximize their future reproductive potential. For management of acute gynecologic pain—such as in cases of adnexal torsion or obstructive anomalies—surgical intervention is often warranted. Pain related to more chronic processes—such as endometriosis—is treated both medically and surgically. Hormonal therapy (either combined estrogen/progestin or progestin-only) is the mainstay of medical therapy. Newer methods, such as the levonorgestrel intrauterine devices (LNG-IUD), show promise as a management option for chronic endometriosis-related pain. The LNG-IUD also provides highly effective long-acting reversible contraception, and is a first-line recommended contraceptive method for adolescents. Other etiologies of gynecologic pain may be infectious and are therefore treated by antibiotics. Providers must perform a thorough history and physical exam—with attention to patient confidentiality. Establishing a good rapport with both patients and their caregivers is crucial. Regular follow-up to assess treatment efficacy is necessary—as certain conditions may require a stepwise progression of treatment modalities for resolution of symptoms. While it is often challenging caring for an adolescent with chronic gynecologic pain, it is also extremely important and rewarding. Optimizing the gynecologic health of adolescent females will allow them to function at their full potential and lead productive, enjoyable lives.

Aim of the Study The goals of urinary reconstruction in urogenital sinus and cloacal repair include: (1) positioning of the bladder neck above the urogenital diaphragm to maximize future urinary continence, and (2) creating a visible urethra that can be catheterized if needed. A recent algorithm in cloacal reconstruction proposed a urethral length of 1.5 cm as the key determinant in deciding whether to perform a total urogenital mobilization or a urogenital separation, the hypothesis being that a 1.5 cm length urethra is needed for the patient to remain dry. We wondered if the normal female urethral length correlated with this empiric technical determinant. Methods We reviewed voiding cystourethrograms of healthy female patients between ages 6 and 36 months and measured the patient's urethral length. Results Ninety-one children were included. The mean urethral length for patients age 6–12 months was 2.50 cm, age 12–24 months was 2.31 cm, and age 24–36 months was 2.59 cm. There was no difference between the urethral length in the three groups (p = 0.38). Of 91 patients, 87 (96%) had a urethral length > 1.5 cm. Conclusion A urethra of at least 1.5 cm was present in the majority of normal control patients. We believe therefore that for urogenital sinus and cloacal repair, surgeons can extrapolate that patients need a 1.5 cm urethra at the end of the reconstruction. Additional follow-up is needed to determine if this urethral length as an independent factor maintains dryness in the long term after cloacal repair. Type of Study Case Series. Level of Evidence III.

Introduction Patients with anorectal malformations (ARM), Hirschsprung disease (HD), and colonic motility disorders often require care from specialists across a variety of fields, including colorectal surgery, urology, gynecology, and GI motility. We sought to describe the process of creating a collaborative process for the care of these complex patients. Methods We developed a model of a devoted center for these conditions that includes physicians, psychologists, social workers, nurses, and advanced practice nurses. Our weekly planning strategy includes a meeting with representatives of all specialties to review all patients prior to evaluation in our multidisciplinary clinic, followed by combined exams under anesthesia or surgical intervention as needed. Results There are 31 people working directly in the Center at present. From the Center's start in 2014 until 2017, 1258 patients were cared for from all 50 United States and 62 countries. 360 patients had an ARM (110 had a cloacal malformation, 11 had cloacal exstrophy), 223 presented with HD, 71 had a spinal malformation or injury causing neurogenic bowel, 321 had severe functional constipation or colonic dysmotility, and 162 had other diagnoses including familial polyposis, Crohn's disease, or ulcerative colitis. We have had 170 multidisciplinary meetings, 170 multispecialty outpatient, and 52 nurse practitioner clinics. In our bowel management program we have seen a total of 514 patients in 36 sessions. Conclusion This is the first report describing the design of a multidisciplinary team approach for patients with colorectal and complex pelvic malformations. We found that approaching these patients in a collaborative way allows for combined medical and surgical decisions with many providers simultaneously, facilitates therapy, and can potentially improve patient outcomes. We hope that this model will help establish new-devoted centers in other locations to encourage centralized care for these rare malformations. Level of evidence IV.

Introduction A significant number of internationally adopted children have congenital birth defects. As a specialist center for colorectal diagnoses, we evaluate such children with an anorectal malformation (ARM) and have found that a significant number need a reoperation. Knowledge of the common complications following ARM surgery has led us to develop treatment algorithms for patients with unknown past medical and surgical history, a situation typically encountered in the adopted population. Methods The results of investigations, indications, and rate of reoperation were assessed for adopted children with an ARM evaluated between 2014 and 2016. Results 56 patients (28 males) were identified. 76.8% required reoperative surgery. Mislocation of the anus outside the sphincter complex was seen in 50% of males and 39.3% of females. Anal stricture, rectal prolapse, retained vaginal septum, and a strictured vaginal introitus were also common. Conclusion The reoperative surgery rate in the internationally adopted child with an ARM is high. Complete, systematic evaluation of these children is required to identify complications following initial repair. Development of mechanisms to improve the primary surgical care these children receive is needed.

Infertility has a negative impact on quality of life among cancer survivors. Studies show establishing a fertility team results in improved patient satisfaction. A review of electronic medical records was performed to examine predictors of fertility referrals, interventions, and the impact of an opt-out consult mechanism. Findings show many patients, particularly those that are younger, are still not receiving fertility counseling despite the presence of a fertility team. Notably, patients were 3.6 times more likely to receive a consult after the opt-out. Strategies are needed to improve access to fertility related care, particularly in groups where consults are underutilized.