Early Vaginal Reconstruction in Complex Anorectal Malformations: Rationale for an Individualized Approach

Background: Current trends in reconstructive surgery increasingly advocate delaying vaginal reconstruction until patients can participate in decision-making. While this approach may be appropriate for conditions such as Mayer–Rokitansky–Küster–Hauser syndrome and isolated vaginal agenesis, its application to patients with complex anorectal malformations (ARM), requires careful consideration. Methods: This narrative review discusses the anatomical, surgical, and psychosocial factors influencing the timing of vaginal reconstruction in patients with complex anorectal malformations. Drawing on contemporary surgical principles and extensive clinical experience with reconstruction, differences between ARM and other causes of vaginal atresia are examined, together with reconstructive options and emerging strategies to preserve future reproductive potential. Results: Patients with complex ARM differ substantially from patients with isolated vaginal agenesis. They frequently present with associated urinary tract anomalies, neurogenic bladder, fecal incontinence as well as previous abdominal and perineal operations. In selected patients, vaginal reconstruction performed during the initial repair offers important technical advantages, including optimal pelvic exposure before fibrosis develops, preservation of surgical options, and avoidance of later operations in a hostile pelvis. The choice of reconstructive tissue should be individualized according to anatomy and anticipated bowel function. Native vaginal tissue remains the preferred option whenever available; however, when replacement is necessary, the rectum provides the most favorable intestinal substitute in appropriately selected patients, followed by colon, whereas small bowel should generally be reserved for situations in which other options are unavailable. Conclusions: Delayed vaginal reconstruction should not be considered the universal standard for patients with anorectal malformations. Surgical timing should be individualized according to anatomical complexity, predicted bowel function, future urological procedures, patient circumstances, and long-term quality-of-life considerations. Management within specialized multidisciplinary centers remains essential for optimizing both functional and reproductive outcomes. Keywords: anorectal malformation; cloaca; vaginal reconstruction; neovagina; colorectal surgery; pediatric surgery.