Sudhakar Jadhav, Amit Raut, Jui Mandke, Santosh Patil, Ravindra Vora, Dinesh Kuttur JIAPS Year : 2013

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

Repair of ARM with rectourethral (RU) fistula involves the separation of two systems. Risk of injury: urethra, ureters, seminal vesicles, bladder & important nerves-urinary control & sexual function.

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 and left the urethral fistula without closing it Rest of the PSARP procedure: the same as conventionally done

34 successive patients Before January 2006 Staged repair of ARM PSARP with closure of RU fistula using interrupted sutures.

Pts with sacral agenesis Such congenital sacral defects can lead to a neurogenic bladder.

Clinical evaluation Parameters studied - urinary stream, urinary dribbling, 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 and bladder.

Group A

Immediate postop : Urinary stream normal NO e/o urinary dribbling/retention/ infection/ recurrent fistula MCU : normal urethra, no e/o stenosis /stricture, urethroejaculatory duct/vasal reflux, or diverticulum Urethrocystoscopy : normally healed urethra

Group B

urethral stenosis (n=2) urethral diverticulum(n=1) neurogenic dysfunction(n=1)

PSARP: urological injuries in male known complications ARM with RU fistula: rectum intimately attached to the urethra meticulous dissection & separation necessary

Traction on the RU fistula i.e. indirect traction on the urethra during separation Using interrupted sutures for its closure Separation of the rectum from the urethra very near the urethral wall

result of a segment of the rectum left attached to 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 segment attached and leaving fistula as it is w/o closure

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

By not doing something i.e. not closing the RU fistula during PSARP, can avoid many complications So, not doing something is preferable here.

Not mandatory to close the RU fistula during PSARP. Nonclosure of the RU fistula avoids urological complications, especially urethral complications.

32 patients with ARM investigated urodynamically In 3 boys with rectourethral fistulas detrusor failure consistent with autonomic denervation noted postoperatively. Std PSARP was performed in 1 & posterior sagittal anorectoplasty combined with additional transabdominal procedures in the other 2 CONCLUSION: PSARP and its variants do not affect lower urinary tract function unless these surgical techniques are combined with major transabdominal procedures and extensive retrovesical dissection.

A total of 129 injuries in 1,003 patients were identified Most significant was that all 27 patients with neurogenic bladder & all 19 of those in group B with urethral injuries did not undergo a distal colostogram to define the level of the fistula before repair. Posterior urethral diverticulae were seen only in cases of recto-bulbar urethral fistulae repaired via an abdominal-perineal approach.

laparoscopic approach was used for rectal dissection, ligation of the fistula, and division of vessels to pull the rectum down in cases of ARM with recto-bladderneck or high prostatic fistula. 15 children (recto-bladderneck fistula, n=13 and rectoprostatic fistula, n =2) in this series: no urethral injuries, posterior urethral diverticula, or rectal strictures. CONCLUSION: combination of laparoscopy & PSARP represents a useful technical alternative that allows for a safe reconstruction in cases of ARM with rectobladderneck and in selected high prostatic fistulas.

Prospective cohort study. Series of patients with anorectal malformations and an externally accessible fistula, underwent pre- and postoperative rectal manometry studies. Preoperative rectal manometry of rectoperineal or rectovestibular fistula showed the presence of functional anal structures within the fistula in all patients. fistula-preserving surgery in patients with anorectal malformations associated with improved bowel function outcome.