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Official Description

Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, sacroperineal approach

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 46744 refers to the surgical procedure known as the repair of a cloacal anomaly through anorectovaginoplasty and urethroplasty, utilizing a sacroperineal approach. Cloacal anomalies are congenital defects that occur exclusively in females, characterized by the abnormal merging of the rectum, vagina, and urethra into a single common channel. This condition necessitates surgical intervention to create separate functional openings for the rectum, vagina, and urethra. The specific surgical approach and repair technique employed depend on the precise nature of the cloacal anomaly and the anatomical configuration of the merging structures. In the case of a low cloacal anomaly, the sacroperineal approach is utilized, which involves making an incision in the posterior aspect of the perineum. This allows for dissection to the presacral space, where the rectal pouch can be identified and mobilized. The procedure aims to restore normal anatomy and function by carefully separating and reconstructing the affected structures, ensuring that the patient can achieve proper bowel and urinary function postoperatively.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The procedure coded as CPT® 46744 is indicated for the surgical repair of cloacal anomalies in female patients. These anomalies are characterized by the abnormal fusion of the rectum, vagina, and urethra, leading to a single common channel. The specific indications for this procedure include:

  • Cloacal Anomaly - A congenital defect where the rectum, vagina, and urethra are merged into one channel, requiring surgical intervention to separate and reconstruct these structures.

2. Procedure

The surgical procedure for CPT® 46744 involves several critical steps, executed in a systematic manner to ensure successful repair of the cloacal anomaly:

  • Step 1: Incision and Dissection - A sacroperineal approach begins with an incision made in the posterior aspect of the perineum. The surgeon carefully dissects through the tissue to reach the presacral space, which is essential for accessing the rectal pouch.
  • Step 2: Identification of the Rectal Pouch - Once the presacral space is accessed, the dissection continues until the rectal pouch is identified. This step is crucial as it allows for the mobilization of the rectal pouch, which is necessary for the subsequent reconstruction.
  • Step 3: Mobilization of the Vagina and Urethra - The vagina and urethra are mobilized together as a single unit. This coordinated mobilization is important for ensuring that both structures can be properly positioned and sutured into place during the repair.
  • Step 4: Identification of Anorectal Muscle Complex - A muscle-stimulator device is utilized to identify and mark the anterior and posterior limits of the anorectal muscle complex. This step is vital for ensuring that the rectum can be accurately sutured to the muscle complex.
  • Step 5: Suturing the Rectum - The rectum is then pulled down and sutured to the anorectal muscle complex, establishing a secure connection that is essential for normal bowel function.
  • Step 6: Suturing the Vagina and Urethra - Similarly, the vagina and urethra are pulled down to the perineum and sutured into place, creating functional openings for both structures.
  • Step 7: Vaginoplasty and Urethroplasty - A vaginoplasty and urethroplasty are performed to construct the functional openings in the perineum, ensuring that both the vaginal and urinary tracts are properly reconstructed.
  • Step 8: Closure of the Sacroperineal Incision - The sacroperineal incision is then closed, completing the surgical repair.
  • Step 9: Creation of the Anal Opening - The skin over the anal sphincter is incised, and the rectal pouch is opened. The rectal mucosa is sutured circumferentially to the skin to create the anal opening, finalizing the reconstruction of the anal canal.

3. Post-Procedure

Post-procedure care following the repair of a cloacal anomaly via CPT® 46744 involves monitoring the patient for any complications and ensuring proper healing of the surgical sites. Patients may require follow-up visits to assess the functionality of the reconstructed openings and to manage any postoperative discomfort. It is essential to provide appropriate wound care instructions and to monitor for signs of infection or other complications. The expected recovery period may vary based on the individual patient's condition and the extent of the surgical repair performed.

Short Descr REPAIR OF CLOACAL ANOMALY
Medium Descr RPR CLOACAL ANOMALY SACROPERINEAL
Long Descr Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, sacroperineal approach
Status Code Active Code
Global Days 090 - Major Surgery
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 2 - Payment restriction for assistants at surgery does not apply to this procedure...
Co-Surgeons (62) 1 - Co-surgeons could be paid, though supporting documentation is required...
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Inpatient Procedures, not paid under OPPS
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P1G - Major procedure - Other
MUE 1
CCS Clinical Classification 132 - Other OR therapeutic procedures, female organs
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
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1994-01-01 Added First appearance in code book in 1994.
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