Perineal Incision Research Articles

TRAUMATIC URINARY DIVERSION CAUSED BY GUNSHOT INJURY IN A STALLION

Summary A seven-year-old stallion with diversion of urinary pass to the thigh due to a urethral fistula caused by gunshot perineal injury was presented to the Urmia University, Veterinary Teaching Hospital. No signs of urinary obstruction or renal failure were observed. Because of inaccessible location of the injured urethra, through a perineal urethrotomy incision, a urinary catheter was effectively advanced to repel the obstruction into the bladder. Retrograde urethral catheterization was adopted for 5 days to assist mucosal healing. Healing was uneventful and no complications were observed during one month postoperative. Key words: Fistula, Urethra, Gunshot, Stallion Introduction The urethra, a muscular tube lined by mucosa, serves as the normal conduit for urine flow to the exterior of the body after birth. The male urethra connects the bladder to the glans penis and consists of pelvic and extrapelvic segments (Sisson and Grossman, 1975). Disorders of the equine penis and urethra that require surgery are principally limited to conditions involving urolithiasis, soft tissue obstructions, contusions, and lacerations (Trotter

Mini-invasive collagen sling in the treatment of urinary incontinence due to sphincteric incompetence

To assess the technical feasibility of mini-invasive sling procedure and present preliminary results in the treatment of urinary incontinence due to sphincteric insufficiency. Thirteen patients (6 males, 7 females, 8 with myelomeningocele, 1 with tethered spinal cord, 3 with bladder exstrophy, 1 with epispadias) underwent sling procedure with porcine dermis acellular collagen matrix (Pelvilace, Bard medical, UK). The median age was 15.5 (range 8.9-27.5) years. A suprapubic catheter was inserted for the measurement of leak point pressure during the operation. In females vaginal and in males perineal incision was used for sling insertion. The sling was introduced under cystoscopic control. The sling was not fixed with sutures. The outcomes were reviewed at 1, 6 and 12 month after the operation. The median leak point pressure increased from 21.5 (range 5-25) cm H2O to 85 (range 70-100) cm H2O. At 1 month 8 and at 6 months 3 out of 13 patients were dry. At 12 months, none out of 11 patients was completely dry. However, at 12 months some improvement in incontinence was detected in 9 out of 11 patients. Two patients had primary failures. One patient got sling erosion to urethra after a tightening attempt. In one patient detrusor overactivity increased after the sling procedure. Pelvilace sling is safe and easy to introduce in both males and females if pelvic floor anatomy is normal. Although immediate results were promising in neuropathic incontinence, the results seem to deteriorate to unacceptable low level already during the first year. In exstrophy patients the results are generally poor.

The male perineal sling for the treatment of neurogenic urinary incontinence

Purpose The treatment of the incompetent bladder neck in boys with neurogenic bladders is difficult. We have adapted the AMS Invance sling to treat this group of patients. This device was originally developed to treat urinary incontinence post-radical prostatectomy. Material and methods The InVance male sling system (AMS) was used in 4 boys with a history of spina bifida and urinary incontinence. The boys ranged in age from 15 years to 19 years. Follow-up ranges to 18 months. Urodynamics confirmed low leak point pressures and adequate vesical compliance and capacity. The procedure was performed on an out-patient basis. A silicone coated polyester sling was placed through a perineal incision. Three titanium screws were used in conjunction with polypropylene sutures to secure the sling on either descending pubic rami. Results A total of five slings were placed in 4 patients. One sling required replacement secondary to inadequate fixation. One sling was removed after a local wound infection developed. Of the 3 patients with the sling in place, all are completely continent. They are able to perform intermittent catheterization without difficulty. Conclusions This out-patient technique offers the potential of achieving long-term urinary continence in boys using a perineal based sling. Further studies of this approach are warranted based on these preliminary results. The treatment of the incompetent bladder neck in boys with neurogenic bladders is difficult. We have adapted the AMS Invance sling to treat this group of patients. This device was originally developed to treat urinary incontinence post-radical prostatectomy. The InVance male sling system (AMS) was used in 4 boys with a history of spina bifida and urinary incontinence. The boys ranged in age from 15 years to 19 years. Follow-up ranges to 18 months. Urodynamics confirmed low leak point pressures and adequate vesical compliance and capacity. The procedure was performed on an out-patient basis. A silicone coated polyester sling was placed through a perineal incision. Three titanium screws were used in conjunction with polypropylene sutures to secure the sling on either descending pubic rami. A total of five slings were placed in 4 patients. One sling required replacement secondary to inadequate fixation. One sling was removed after a local wound infection developed. Of the 3 patients with the sling in place, all are completely continent. They are able to perform intermittent catheterization without difficulty. This out-patient technique offers the potential of achieving long-term urinary continence in boys using a perineal based sling. Further studies of this approach are warranted based on these preliminary results.

Complications and Sexual Function After Vaginectomy for Anorectal Tumors

The objective of this study was to determine complication rates and functional outcomes of females who underwent vaginectomy during anorectal tumor resection and to determine whether flap reconstruction of the vagina improves sexual function. A retrospective review was performed of all females who underwent multivisceral resections involving the vagina for anorectal tumors at two academic hospitals from 1985 to 2004. Living patients were contacted, and a 25-question telephone questionnaire was administered. Fifty-four patients were identified. Nineteen patients had flap reconstruction of the vagina and 35 had primary repair. Eighty-three percent of patients experienced surgical complications, including perineal wound complications in 33 percent (14/42) of those with perineal incisions and vaginal complications in 41 percent (22/54) of the cohort. There was a nonsignificant decrease in perineal wound complications when flap reconstruction was performed (22 vs. 42 percent). Twenty-three patients completed the questionnaire (96 percent of those eligible). Six patients were able to have sexual intercourse after surgery and nine were not. Reasons for inability to have sexual intercourse were: inadequate vaginal capacity (n = 4), pain (n = 2), and chronic wound or fistula (n = 3). No living patients who had flap reconstruction were able to have sexual intercourse. Only 20 percent of patients remembered a preoperative discussion of possible sexual effects of surgery; however, overall quality of life was preserved. Anorectal tumor resections involving the vagina are associated with a high rate of complications, including inability to have intercourse after surgery, even with flap reconstruction. Females should be counseled regarding potential loss of sexual function.

Laparoscopic Radical Cystoprostatectomy and in Block Urethrectomy in Urethral Cancer: Initial Experience in 2 Cases

We introduce laparoscopic radical cystoprostatectomy and in block urethrectomy as an option for the treatment of urethral cancer in men. Using a 5-port transperitoneal approach, a radical cystoprostatectomy is completed laparoscopically with bilateral iliac and pelvic lymphadenectomy. Urethrectomy and extraction of bladder and prostate is performed through a perineal incision. A segment of ileum is isolated and exteriorized to create an extracorporeal ileal conduit and restore ileo-ileal continuity by open standard technique. Bilateral stented uretero-ileal anastomosis is extracorporeally performed. Total operative time ranges from 4.5 to 4.8 hours. Laparoscopic radical cystoprostatectomy with perineal urethrectomy and an extracorporeally made ileal conduit is a feasible technique that can be reproduced. To our knowledge, this is the first report of laparoscopic radical surgery in the treatment of urethral cancer in men.

Ultrasound-assisted repair of a unique case of distal vaginal agenesis

To describe a unique vaginal outlet obstruction and its ultrasound-assisted surgical correction. Case report. An academic medical center. A 12-year-old girl was seen with cyclic abdominal pain, nausea, and an abdominal mass. External genital examination revealed no vaginal opening or dimple. Transabdominal ultrasound revealed a large hematometrocolpos 5 cm proximal to the perineum, with an otherwise normal-appearing uterus and ovaries. Surgical treatment included perineal incision, creation of a 5-cm passage through connective tissue, drainage of the hematometrocolpos, and mobilization of the proximal vagina, allowing for pull-through vaginoplasty. Ultrasound guidance was used throughout the surgery and allowed for a safe transperineal approach. A vaginal form was placed in the neovagina. Follow-up clinical evaluation and pelvic ultrasonography. A well-healed perineum and patent 5-cm-long vagina were observed at 4-month follow-up. The patient reported three regular menses. Postoperative pelvic ultrasound scan was normal. We describe a unique case of isolated distal vaginal agenesis of significant length that was successfully treated via a perineal approach with the intra-operative assistance of ultrasound guidance.

Implantación del Esfínter Urinario Artificial “FlowSecureTM” en uretra bulbar: Descripción de la técnica quirúrgica paso a paso

introductionWe have implanted the FlowSecure artificial sphincter for the first time in October 2006. The prototype was originally conceived and designed by Professor Craggs M. D. and Professor Mundy A.R. Preliminary clinical results were reported in nine patients early this year. Our objective is to spread technique for surgical implantation. MethodsCombined perineal and abdominal incisions are required for exposure of bulbar urethra, creation of a cavity in the para-vesical space and dissection of a pocket under de scrotal wall. A trocar with a stylet is routed from the abdominal incision to the perineal incision to pass the deflated cuff to the perineal site. The cuff is placed around the urethra and secured with Prolene sutures. After refilling the cuff, fluid is removed from the system until the stress relief balloon becomes just indented (atmospheric pressure 0). The pump is placed in the scrotum and the balloons in the paravesical space. ResultsWe have implanted our first FlowSecure artificial sphincter in a patient with severe stress incontinence following a T.U.R.P. The surgical technique is simple and associated with little handling. He was discharged from hospital 4 days after the procedure and it was decided that pressurisation was unnecessary. DiscussionSurgical implantation of the new FlowSecure artificial urinary sphincter is an easy procedure in males with stress urinary incontinence. Knigth et al. reported 30 to 40 minutes operating time, 4 days mean hospital stay and unnecessary pressurisation procedure in 3 out of their 9 patients. It seems that their results are reproducible.

Outcome of dorsal onlay buccal mucosa substitution urethroplasty in long strictures of anterior urethra

Background: The surgical treatment of adult anterior urethral strictures is constantly evolving. Controversy exists over the best means of reconstructing the anterior urethra. Methods: Twelve patients underwent buccal mucosal urethroplasty for long segment anterior urethral stricture between 2003 and 2005. Eleven patients with a salvageable urethral plate were treated with one stage dorsal onlay urethroplasty, using a perineal or circumcoronal incision. One patient with a severely scarred urethral plate underwent two-stage urethroplasty. Results: At a mean follow up of 14.2 months (range 2 to 26) one (8.3%) patient had short recurrent stricture, which was treated with optical urethrotomy. The mean maximal urine flow rate improved from 8.3 ml/sec to 18.1 ml/sec after the surgery. There were no donor site complications. All patients had a normal slit like meatus and none had chordee or erectile dysfunction. Conclusion: In long stricture of anterior urethra, dorsal onlay buccal mucosa urethroplasty provides excellent intermediate term results with a normal, wide caliber urethra.

External Pelvic Rectal Suspension (the Express Procedure) for Internal Rectal Prolapse, with or without Concomitant Rectocele Repair: A Video Demonstration

Internal rectal prolapse has been proposed as a cause of symptomatic rectal evacuatory dysfunction. Abdominal rectopexy, the standard surgical approach, has significant attendant risk and does not address any concomitant rectocele. This video was designed to demonstrate a novel surgical method that uses porcine collagen implants (Permacol), designed to correct internal rectal prolapse, with or without rectocele. severe rectal evacuatory dysfunction refractory to maximal conservative therapy and full-thickness internal rectal prolapse impeding rectal emptying on defecography with or without associated functional rectocoele; normal colonic transit. Patients undergo comprehensive preoperative and postoperative symptomatic assessment and anorectal physiologic testing, including defecography. A crescenteric perineal skin incision allows development of the rectovaginal/rectoprostatic plane to Denonvilliers fascia, with rectal mobilization. A curved tunneller inserted via the perineal wound is guided retropubically to emerge through suprapubic wounds created on each side. Permacol T-strips are sutured to the anterolateral rectal wall bilaterally, upward traction exerted, and the stem of each T-strip is sutured to the suprapubic periosteum, suspending the rectum. Concomitant rectocele is repaired using a Permacol patch in the rectovaginal plane. Short-term results for the "Express" are encouraging with improvement in evacuatory and prolapse symptoms and concomitant anatomic improvement at defecography. This procedure promises to be an effective technique for managing patients with refractory evacuatory dysfunction secondary to internal rectal prolapse, with or without rectocele.

Clinic Observing between Lateral Perineal Incision and Median Perineal Incision

目的 探讨会阴切开术的最佳方法.方法 观察我院自然分娩的初产妇220例,其中会阴侧切110例为对照组,会阴正中切110例为观察组,两组均采用00、000爱惜康快薇荞缝合.结果 观察组在缝合时间上明显短于对照组,P＜0.01,对照组伤口感染裂开3例,观察组无感染裂开.结论 会阴正中切开术具有创面小,出血少,产妇痛苦小,感染率低,产后康复质量高。

Bulbourethral Composite Suspension for Treatment of Male-Acquired Urinary Incontinence

ObjectivesWe evaluated the efficacy of bulbourethral composite sling procedure in the treatment of male urinary incontinence after radical prostatectomy, transurethral resection of the prostate, or prostatic enucleation for benign prostatic hyperplasia, and posterior urethroplasty. MethodsBetween May 2000 and April 2005, a bulbourethral composite sling was performed in 26 patients with acquired urinary incontinence. Eight (30.8%) of these patients had severe urinary incontinence, and 18 (69.2%) had mild to moderate urinary incontinence. A polyester patch plus tension-free vaginal tape (TVT) device was used in the procedure. Prolene threads were attached to the two ends of polyester taper then passed from the perineal incision to a suprapubic incision with a TVT needle. The ends of the sutures and TVT were tied over the rectus fascia in the midline after repeated urethral pressure measurements reached 80–90cmH2O. ResultsThe follow-up period was 8–54 mo (mean: 28.3). The primary procedure failed in one patient. Of the remaining 25 patients, 1 patient died of cerebral hemorrhage 2 yr postoperatively, and 2 patients had recurrent stress incontinence in 1.5 and 2 yr postsurgery, respectively. The recurrent incontinence was severe in one patient and mild (one to two pads per day) in the other. The remaining 22 patients maintained urination and continence. The total success rate (cure and improved) was 92% (23 of 25). ConclusionsBulbourethral composite sling procedure is a minimally invasive, safe, effective surgical option in the treatment of male patients with mild to moderate incontinence, but is not suitable for severe incontinence. Temporary perineal discomfort or pain is a common complication of the procedure.

Minimal Access Surgery in the Neonate

After completing this article, readers should be able to: 1. Review physiologic, anatomic, and technical issues related to minimal access surgery in the neonate. 2. Describe conditions in which minimal access surgery can be used in neonates. Historically, pediatric surgeons were slow to adapt to minimal access surgery (MAS) techniques compared with the adult surgical community. However, MAS now is widely established in infants and children. Differences in size and physiology have necessitated a number of surgical and technological modifications to apply MAS techniques to this population. This review outlines the important differences between children and adults with respect to MAS and provides examples of the use of MAS for diseases seen in infants. ### Physiologic Issues The physiologic response to pneumoperitoneum in children is more pronounced than in adults. Peritoneal insufflation with carbon dioxide has been shown to cause hypercarbia, acidemia, and decreased oxygenation in the pediatric piglet model. (1) In infants, however, there is no detrimental effect on blood pressure, heart rate, or oxygen saturation during short periods of pneumoperitoneum, and elevations in end-tidal CO2 can be counteracted readily by increasing the minute ventilation. (2) Hypercarbia-induced pneumoperitoneum in infants is associated with changes in cerebral blood flow and cardiac output. Nevertheless, laparoscopic procedures have been performed safely with proper anesthetic management in children who have even severe congenital cardiac abnormalities such as hypoplastic left heart syndrome. (3) Hypothermia also can be a concern due to rapid insufflation of unwarmed CO2 gas, mandating the moderation of flow rates. (4) ### Anatomic Issues A number of anatomic factors set children apart from adults and must be accounted for when performing laparoscopic surgery in this age group. Young children and infants have thinner abdominal walls than adults, so extreme care must be exercised when placing trocars. Due to the small size of the abdomen, the working …

Recurrence in a Schuchardt incision after Schauta-Amreich radical vaginal hysterectomy for cervical cancer

A Schuchardt incision is frequently performed to facilitate access to the parametrium during radical vaginal hysterectomy for cervical cancer. We report an adenocarcinoma recurrence in a Schuchardt incision 12 months after radical vaginal hysterectomy for FIGO stage IB1 cervical cancer. Histology of the primary tumor had shown a well-differentiated adenocarcinoma and poorly differentiated squamous cell carcinoma of the cervix 2.6 cm in maximum diameter. After further surgical therapy and adjuvant radiotherapy, the patient died of disease 51 months after the initial operation. Cervical cancers can implant and recur in perineal incisions. Thus, it appears prudent to avoid such incisions or, if they are made, to irrigate them copiously before closing them.

Dorsal Buccal Mucosal Graft Urethroplasty by a Ventral Sagittal Urethrotomy and Minimal-Access Perineal Approach for Anterior Urethral Stricture

OBJECTIVE To present the technique of dorsal buccal mucosal graft urethroplasty through a ventral sagittal urethrotomy and minimal access perineal approach for anterior urethral stricture. PATIENTS AND METHODS From July 2001 to December 2002, 12 patients with a long anterior urethral stricture had the anterior urethra reconstructed, using a one-stage urethroplasty with a dorsal onlay buccal mucosal graft through a ventral sagittal urethrotomy. The urethra was approached via a small perineal incision irrespective of the site and length of the stricture. The penis was everted through the perineal wound. No urethral dissection was used on laterally or dorsally, so as not to jeopardize the blood supply. RESULTS The mean (range) length of the stricture was 5 (3-16) cm and the follow-up 12 (10-16) months. The results were good in 11 of the 12 patients. One patient developed a stricture at the proximal anastomotic site and required optical internal urethrotomy. CONCLUSION Dorsal buccal mucosal graft urethroplasty via a minimal access perineal approach is a simple technique with a good surgical outcome; it does not require urethral dissection and mobilization and hence preserves the blood supply.

Recurrence in a Schuchardt incision after Schauta–Amreich radical vaginal hysterectomy for cervical cancer

A Schuchardt incision is frequently performed to facilitate access to the parametrium during radical vaginal hysterectomy for cervical cancer. We report an adenocarcinoma recurrence in a Schuchardt incision 12 months after radical vaginal hysterectomy for FIGO stage IB1 cervical cancer. Histology of the primary tumor had shown a well-differentiated adenocarcinoma and poorly differentiated squamous cell carcinoma of the cervix 2.6 cm in maximum diameter. After further surgical therapy and adjuvant radiotherapy, the patient died of disease 51 months after the initial operation. Cervical cancers can implant and recur in perineal incisions. Thus, it appears prudent to avoid such incisions or, if they are made, to irrigate them copiously before closing them.

Bulbocavernosus muscle flap in the repair of complicated vesicovaginal fistula

To investigate the transposition of the bulbocavernosus muscle flap for repairing complicated vesicovaginal fistulas. Vesicovaginal fistulas were repaired via combined abdominal and perineal approaches. Through an abdominal approach, the fistula and surrounding scar tissue were excised thoroughly. A perineal incision was made between the orifices of the urethra and the vagina, dissecting until the fistula. The vaginal defect was closed through either the abdominal or the perineal approach depending upon its position. Through the abdominal approach, the bladder defect was closed in two layers with the suture lines vertical to each other. The bulbocavernosus muscle was freed through an incision between the labium majus pudendi and the labium minus pudenda, without damaging the pudendal vascular supply. The bulbocavernosus muscle flap was tunneled beneath the labium minus pudendi, and was sutured in place on the bladder wall over the fistula repair site. Nine patients with complicated vesicovaginal fistulas were treated using this technique. After surgery, no symptoms of vagina leakage, urinary incontinence, or urethral stricture were reported by any of the patients, and they reported normal sexual function. Transposition of the bulbocavernosus muscle flap is an excellent technique with low morbidity and high success rate for repairing complicated vesicovaginal fistulas.

New surgical technique for sphincter urinary control system using upper transverse scrotal incision.

Traditional implantation of the AMS Sphincter 800 Urinary Control System (American Medical Systems, Minnetonka, Minnesota) requires 2 incisions. The cuff is placed via a perineal incision, and the pressure regulating balloon and pump are placed through a separate suprapubic incision. We describe a novel implantation of all the artificial urinary sphincter components using a single upper scrotal incision. The scrotal incision allows excellent access to the proximal bulbar urethra and retropubic and subdartos spaces, and leaves the bulbocavernosus muscle intact. A total of 37 patients have undergone artificial urinary sphincter implantation using the new operative technique for revisions or reimplantations of a sphincter previously removed for infection/erosion (12) or as an initial procedure (25). In 9 of the 25 patients and 2 of the 12 dual implantation of a 3-piece penile prosthesis through the same incision was performed. All patients are using the devices. Of the patients 66% are completely dry with no pad use and the remainder use 1 pad for accident prevention. Operative time was reduced due to easier exposure of the urethra and a second incision for placement of the pressure regulating balloon was not necessary. Followup at 1 year shows no difference in complication rate with the single incision technique compared to the traditional method. Artificial urinary sphincter implantation through a single scrotal incision is easier and faster than the traditional 2-incision technique. Success in achieving continence is similar to traditional methods. Long-term followup is necessary to ensure that complications remain low.

Evaluation of two techniques of partial urethral obstruction in the male rat model of bladder outlet obstruction

Objectives To perform a comparison to determine which of two methods of partial urethral ligation produces the most consistent outcome and fewest side effects. Such a study has not been previously reported. Partial urethral ligation is a means of causing reproducible bladder outlet obstruction. In the male rat model, partial urethral obstruction can be performed either by perineal incision and bulbous urethral ligation or retropubic incision and midprostatic obstruction. Methods Fifteen male Sprague-Dawley rats were studied. Five were selected for bulbous urethral obstruction through a perineal incision, five for midprostatic obstruction using a retropubic approach, and five for a sham operation through a perineal incision. Results The operative time was shorter and morbidity lower with the perineal approach compared with the retropubic approach. Inflammation or infection, or both, were seen in the prostate, bladder, proximal urethra, ureters, and kidneys in the rats in which a midprostatic obstruction was performed. The proximal urethra and prostate were mildly inflamed in those rats that underwent bulbous obstruction. Sham-operated rats exhibited mild prostatitis only. Conclusions The perineal approach to the bulbous urethra is the method of choice for creating a partial urethral obstruction model of bladder outlet obstruction in the male rat.

Incisional endometriosis after cesarean section, episiotomy and other gynecologic procedures

To report 11 cases of incisional endometriosis after cesarean section, episiotomy and other gynecologic procedures. The diagnostic approaches and therapies for incisional endometriosis are also evaluated. Eleven patients who presented with a painful nodule that was increasing in size during menstruation on the scar of a previous gynecologic procedure were examined retrospectively. All patients presented with a palpable painful lesion, located on the cesarean section incision, perineal episiotomy incision or the vaginal cuff after hysterectomy. All masses were increasing during menstruation and all patients had been having cyclical pain that worsened during menstrual periods. The mean age of the patients was 28.2 years. The onset of symptoms was referred at variable intervals after surgery ranging between 2 and 11 years (mean: 5.72 years). Ultrasound examination confirmed hypoechoic mass septated with cystic and solid components in the abdomen without intra-abdominal communications. All endometriotic masses were completely excised under general anesthesia. The excised masses were sent for microscopic examination which confirmed the diagnosis of endometriosis. Incisional endometriosis seems to be common in women who have had a cesarean section, although it does occur after other procedures and de novo. It is suggested that caution is exercised during gynecologic procedures to avoid transplantation of endometrium to the anterior abdominal wall. The preferred management is to excise the lesion completely even if this necessitates fascial excision.

Perineal skin bridge and levator muscle preservation in neutral sagittal anorectoplasty (NSARP) for vestibular fistula

The incision in limited posterior sagittal anorectoplasty for vestibular fistula (VF) extends from the coccyx to the fistula with the rectum identified by partial sagittal division of the levator muscle. In anterior sagittal anorectoplasty, the perineal incision extends from the fistula opening to the posterior margin of the external sphincter complex while preserving intact the levator muscle. We describe a modification of the operation for repair of VF, the neutral sagittal anorectoplasty (NSARP), which preserves both a perineal skin bridge between the neo-anus and the posterior fourchette and the levator muscle. Leaving the perineal skin bridge and the levator muscle intact could be important both from the aspects of perineal wound-healing and functional outcome. The skin incision in NSARP extends from the coccyx to the anterior limit of the external sphincter muscle complex as defined by muscle stimulation. An artery forceps passed through the VF facilitates the location and exposure of the rectum. The levator muscle is left intact. The dissection and closure of the VF is done entirely from within the opened rectum. There is an intact perineal skin bridge between the neo-anus and the posterior fourchette at the completion of the NSARP. In 12 consecutive patients with VF, NSARP prevented the risk of wound complications occurring between the neo-anus and the posterior fourchette. A diverting colostomy was safely avoided in our last five patients. NSARP does not involve any division of the levator muscle and it also retains an undisturbed wad of tissue that could function as the perineal body. All five patients who are 3 years or older demonstrate voluntary bowel movements. Preserving the perineal skin bridge and the levator muscle in NSARP have contributed to the improvement of aesthetic appearance of the perineum and faecal continence in our patients.