nonclosure of rectourethral fistula during posterior sagittal anorectoplasty

7/28/2019 Nonclosure of Rectourethral Fistula During Posterior Sagittal Anorectoplasty

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Sudhakar Jadhav, Amit Raut, Jui Mandke, Santosh Patil,Ravindra Vora, Dinesh Kuttur

JIAPS

Year : 2013 ,Volume : 18 , Issue : 1 ,Page : 5-6


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Repair of ARM with rectourethral (RU) fistulainvolves the separation of two systems.

Risk of injury: urethra, ureters, seminal

vesicles, bladder & important nerves-urinarycontrol & sexual function.


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34 pts of ARM with RU fistula

PSARP without closure of RU fistula

From February 2006 to January 2010

Just separated the rectum from the urethra andleft the urethral fistula without closing it

Rest of the PSARP procedure: the same as

conventionally done


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34 successive patients

Before January 2006

Staged repair of ARM

PSARP with closure of RU fistula usinginterrupted sutures.


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Pts with sacral agenesis

Such congenital sacral defects can lead to aneurogenic bladder.


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Clinical evaluation

Parameters studied - urinary stream, urinarydribbling, UTI & recurrent RU fistula

Perurethral catheter removed 6th postop day

Investigations :

MCU : preop & postop - 3 m after

Cystoscopy after 3 m: status of the urethra andbladder.


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Group B

urethral stenosis(n=2)

urethraldiverticulum(n=1)

neurogenicdysfunction(n=1)


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PSARP: urological injuries in male knowncomplications

ARM with RU fistula: rectum intimately

attached to the urethra meticulous dissection & separation necessary


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Traction on the RU fistula i.e. indirect tractionon the urethra during separation

Using interrupted sutures for its closure

Separation of the rectum from the urethra verynear the urethral wall


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result of a segment of the rectum left attachedto the urethra & the separated end closed

usually present with recurrent UTI, stone

formations avoided by separating the rectum away from

the urethra without leaving any segmentattached and leaving fistula as it is w/o closure


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In the form of neurogenic bladder/impotence/loss of ejaculation

Neurogenic bladder d/t denervation of

bladder & bladder neck during repair. Non closure of fistula:

avoids excessive traction on fistula -> urethra

prevents excessive dissection -> denervation damage to the external vesical sphincter


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By not doing something i.e. not closing the RUfistula during PSARP, can avoid manycomplications

So, not doing something is preferable here.


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Not mandatory to close the RU fistula duringPSARP.

Nonclosure of the RU fistula avoids urological

complications, especially urethralcomplications.


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32 patients with ARM investigated urodynamically

In 3 boys with rectourethral fistulas detrusor failure

consistent with autonomic denervation notedpostoperatively.

Std PSARP was performed in 1 & posterior sagittalanorectoplasty combined with additionaltransabdominal procedures in the other 2

CONCLUSION: PSARP and its variants do not affectlower urinary tract function unless these surgicaltechniques are combined with major transabdominalprocedures and extensive retrovesical dissection.


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A total of 129 injuries in 1,003 patients were identified

Most significant was that all 27 patients withneurogenic bladder & all 19 of those in group B withurethral injuries did not undergo a distal colostogramto define the level of the fistula before repair.

Posterior urethral diverticulae were seen only in casesof recto-bulbar urethral fistulae repaired via anabdominal-perineal approach.


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laparoscopic approach was used for rectal dissection,ligation of the fistula, and division of vessels to pull therectum down in cases of ARM with recto-bladderneck

or high prostatic fistula. 15 children (recto-bladderneck fistula, n=13 and recto-

prostatic fistula, n =2) in this series: no urethralinjuries, posterior urethral diverticula, or rectalstrictures.

CONCLUSION: combination of laparoscopy & PSARPrepresents a useful technical alternative that allows fora safe reconstruction in cases of ARM with recto-bladderneck and in selected high prostatic fistulas.


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Prospective cohort study.

Series of patients with anorectal malformations and an externallyaccessible fistula, underwent pre- and postoperative rectalmanometry studies.

Preoperative rectal manometry of rectoperineal or rectovestibularfistula showed the presence of functional anal structures withinthe fistula in all patients.

fistula-preserving surgery in patients with anorectalmalformations associated with improved bowel functionoutcome.


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nonclosure of rectourethral fistula during posterior sagittal anorectoplasty

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