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through procedure at an OSH via a sagittal incision for treatment of the imperforate anus. A small vagina was identified high on the right which was found to be “short” and connected to a “short uterus” with an associated tube and ovary. It was surgically lengthened with flaps from the labia and connected to the introitus. A small fistula going from the vagina to a ureteral remnant from a dysplastic kidney was identified, divided, and ligated. She subsequently did well. Signs of pubertal development were evident at age 10 e 11, with normal breast development and accelerated growth; however, menarche was absent. At age 14, she presented for evaluation of primary amenorrhea and pain. Ultrasound identified two uterine horns, a right ovary, and a distended fluid filled vagina. MRI showed a hematocolpos which appeared contiguous with the right corpus and tube. Left rudimentary uterine corpus and tube were not fluid filler. A re-do vaginoplasty was planned. EUA demonstrated extensive scar tissue with a stricture at 1.5cm from the introitus. Given the history of prior urologic and rectal surgery, and the fact that her unicornuate system was not midline, intra-operative ultrasound was used to identify the inferior aspect of the hematocolpos. With ultrasound guidance a long spinal needle was advanced until it was noted to enter the inferior aspect of the obstructed vagina (Figure 2). Once the angle and direction of dissection was determined, electrocautery was used to carry the dissection upwards. The intervening tissue was excised and 900cc of old blood was evacuated. Vaginal mucosa was identified and a standard pull through vaginalplasty was performed. Vaginal pull through is the standard treatment for lower vaginal agenesis. With a single midline uterus, cervix and upper vagina, the distal aspect of the obstructed upper vagina can be identified by palpation, and