CPT® Code 46748

1. Indications

The procedure coded as CPT® 46748 is indicated for the surgical repair of high cloacal anomalies in females. These anomalies are characterized by the abnormal fusion of the rectum, vagina, and urethra into a single channel, which can lead to significant functional and anatomical challenges. The indications for this procedure include:

• High Cloacal Anomaly This condition requires surgical intervention to separate and reconstruct the rectum, vagina, and urethra to restore normal function.
• Functional Impairment Patients may experience difficulties with bowel and urinary function due to the merging of these structures, necessitating surgical repair.
• Anatomical Reconstruction The procedure aims to create distinct and functional openings for the rectum, vagina, and urethra, which are essential for normal physiological function.

2. Procedure

The surgical procedure for CPT® 46748 involves several critical steps, which are detailed as follows:

• Combined Abdominal and Sacroperineal Approach The surgeon begins by making an incision in the lower abdomen, which is extended down to the bladder and rectum. This approach allows for direct access to the affected structures.
• Mobilization of Rectum, Vagina, and Urethra The rectum is carefully mobilized, and the vagina and urethra are also mobilized as a single unit. This step is crucial for the subsequent reconstruction of these structures.
• Separation of Urogenital Structures In cases of high cloaca, the vagina and urinary tract must be separated to achieve the necessary length for proper positioning at the perineum. This is accomplished through meticulous dissection of the surrounding tissues.
• Vaginal Lengthening A segment of small intestine or colon is harvested and prepared for grafting. This intestinal graft is shaped and sutured to the vaginal remnant to achieve the required lengthening. Alternatively, pedicle flaps from adjacent tissues may be used for this purpose.
• Construction of Functional Openings Following the lengthening, vaginoplasty and urethroplasty are performed to create functional openings in the perineum, ensuring that both the vaginal and urethral canals are properly reconstructed.
• Closure of Incisions The sacroperineal incision is then closed, and the skin over the anal sphincter is incised. The rectal pouch is opened, and the rectal mucosa is sutured circumferentially to the skin to establish the anal opening.

3. Post-Procedure

After the completion of the surgical procedure, patients typically require careful monitoring and post-operative care. This includes managing pain, monitoring for any signs of infection, and ensuring proper healing of the surgical sites. Patients may also need follow-up appointments to assess the functionality of the reconstructed structures and to address any complications that may arise. Rehabilitation may be necessary to support the patient in adapting to the anatomical changes and to ensure optimal recovery.