Cystoscope-guided trans-anal Fistula-tract Laser Closure (FiLaC) of late onset recurrent recto-urethral fistula post anorectal malformation repair: A case report

Abstract

Management of persistent and recurrent rectourethral fistula after primary treatment of anorectal malformations (ARM) is challenging. Various surgical techniques have been proposed and until today there is no consensus on the optimal approach. We describe a case of late onset recurrent rectourethral fistula after neonatal ARM repair, treated with a minimally invasive cystoscope-guided trans-anal Fistula-tract Laser Closure (FiLaC). A male patient suffering from ARM, type recto-bulbar fistula, was treated with an anorectoplasty during the neonatal period. Post-operatively, no reoperations were needed and long term follow-up demonstrated good functional outcome. At the age of 19 years, the patient presented with complaints of anal urinary leakage during micturition. Voiding-cysto-urethrography and perineal Nuclear Magnetic Resonance (NMR) demonstrated a fistula tract between the bulbar urethra and the distal rectum. Given the lack of associated urinary tract infections or fecaluria and the absence of fecal or urinary incontinence in between micturition, we decided to perform a trans-luminal, non-surgical approach. By analogy with the minimally invasive laser treatment of peri-anal fistula in adults, we performed a trans-anal cystoscope-guided FiLaC. We observed a fast post-operative recovery with an excellent one-year follow-up, illustrated by the elimination of symptoms, absence of fistula opening on rectoscopy and disappearance of the fistula-tract continuity on voiding-cysto-urethrography. This case exemplifies the potential benefits of using minimally invasive FiLaC treatment for the management of recurrent and persistent recto-urethral fistula following primary treatment of ARM. Long term follow-up is awaited to confirm the value of FiLaC in this treatment setting.