Prostatic Fistula Research Articles

Management of acquired prostatic fistulas in adults

PurposeAcquired prostatic fistula (PF) was defined as a connection between the prostatic urethra and the rectum, symphysis, peritoneum, or ending freely in the periprostatic area. This study aims to report our experience with PF presentation, diagnosis, and treatment.MethodsFrom January 2014 to February 2024, we retrospectively analyzed a prospectively maintained database from two urologic university hospitals to identify men with acquired PF. Diagnosis was based on post-intervention symptoms, including pneumaturia, fecaluria, rectal urine leakage, periprostatic inflammation or abscess, completed by radiological assessment using retrograde urethrogram, CT, or MRI. Standard cystoscopy and/or rectosigmoidoscopy assessed bladder and rectal integrity. Patients with post-prostatectomy fistulas were excluded.ResultsThirteen patients with a mean age of 66.54 ± 7.40 years were identified. The most commonly presenting symptoms were fecaluria/pneumaturia 54%, rectal urine leakage 31%, and recurrent urinary tract infection 31%. The mean time from the initial treatment to fistula development was 22.28 ± 20.53 months (0.1–59 months), and from diagnosis to repair was 3.5 ± 3 months (1–12 months). Cumulative closure rates (success rate) post-first and second attempts were 77% (10 patients) and 92% (12 patients), respectively; one patient declined definitive surgery, maintaining a persistent fistula after bladder drainage.ConclusionClinical suspicion and detailed diagnosis are essential for formulating a tailored treatment plan for prostatic fistulas, which are successfully manageable in many patients. Complex cases benefit from a multidisciplinary approach, with individualized therapy based on etiology, severity, and recurrence of PF, facilitating effective closure.

Comparison of Urinary Diversion in Patients With Prostatic Fistula to Those with Localized Radiation Injury After Radiotherapy for the Treatment of Prostate Cancer

ObjectivesTo compare characteristics and outcomes in patients who had radiotherapy (RT) for prostate cancer (PCa) and underwent urinary diversion (UD) due to prostatic fistula (Fistula) vs. localized radiation injury (Localized). MethodsThis study was a retrospective single-institution study. Exclusion criteria included: follow-up < 3 months, large pelvic tumor, and surgery for cancer control. The Fistula group included fistulization outside of the urinary tract (rectal, soft tissue, thigh, pubic symphysis, and extensive necrosis surrounding the prostate). The group Localized had a multitude of problems; however, all were confined to the urinary tract. Patient characteristics, perioperative variables, and outcomes were compared between groups. Results69 patients were included and had UD from 2009-2022. Median age and time from RT to UD were 73 (IQR-67.9,78.1) and 7.3 (IQR-3.2,12.5) years. There were 29 (42%) and 40 (58%) patients in the Fistula and Localized groups. The Fistula group had a higher rate of abdominal/perineal approach (62.1% vs. 12.5%,p<0.001), a lower rate of right colon pouch (17.2% vs. 40%,p=0.043), and a longer operative time (515.7 vs 414.2 mins,p=0.017). Clavien-Dindo complications ≥ 3 were higher in the Fistula group (44.8% vs. 20%,p=0.027), including a higher rate of re-operation for recurrent pelvic abscess (37.9% vs. 5%,p<0.001). Survival for the cohort was 85.5% and did not differ between groups. ConclusionsPatients with prostate fistula after RT for PCa undergoing UD had longer, more complex operations, and higher rates of complications, notably post-operative pelvic abscesses, compared to men with localized RT injury. Long-term survival was comparable in both groups.

Postoperative complications in males with anorectal malformations depending on the surgical approach

BACKGROUND: Anorectal abnormalities occur in 1:1,500 to 1:5,000 live births. There is still no agreement on the best surgical procedure for treating some types of anorectal abnormalities in males. Anorectoplasty could be performed using the posterior sagittal approach and using laparoscopic techniques.&#x0D; AIM: To assess the risk of postoperative complications and determine their specificity in males with anorectal malformations, depending on the surgery approach.&#x0D; MATERIALS AND METHODS: A single-center retrospective cohort study was performed. Male patients with anorectal malformations who had surgical correction of anorectal malformation by posterior sagittal (group I) or laparoscopic-assisted anorectoplasty (group II) at the age of up to 1 yr at the N.F. Filatov Childrens City Clinical Hospital from 2008 to 2022. Postoperative and intraoperative problems and the number of surgical interventions that had to be redone to correct issues were noted.&#x0D; RESULTS: Of the 33 patients in group I, 18 (55%) had anorectal malformations with bulbar fistula, 12 (36%) had anorectal malformations without fistula, and three (9%) had a prostatic fistula. Group II included 99 patients, with 53 (54%) having anorectal malformations with prostatic fistula, 30 (30%) having anorectal malformations with bulbar fistula, nine (9%) having anorectal malformations with bladder neck fistula, and seven (7%) having anorectal malformations without a fistula. The incidence of intraoperative and postoperative complications was statistically significantly higher in children after posterior sagittal anorectoplasty than laparoscopic-assisted anorectoplasty: I, 19 (58%) versus II, 33 (33%); p = 0.014. The number of redo surgical interventions to correct complications did not differ significantly between the studied groups: I, 8 (24%) versus II, 26 (26%); p = 0.819. The incidence of urethral damage was identified with posterior sagittal anorectoplasty compared with laparoscopic-assisted anorectoplasty: I, 4 (12%) versus II, 0 (0%); p 0.001. We found no differences in postoperative complications between laparoscopic-assisted and posterior sagittal anorectoplasty.&#x0D; CONCLUSIONS: The results define laparoscopic-assisted anorectoplasty as a viable and promising method that does not have specific postoperative complications if it is technically correctly performed. It is necessary to develop clear criteria for rectum mobilization and the volume of rectourethral fistula dissection during laparoscopic-assisted surgery to reduce the risks of postoperative problems and repeat surgery.

Stricture rate in patients after the repair of anorectal malformation following a standardized dilation protocol.

The aim of this study was to determine and analyze the stricture rate in patients who underwent a PSARP or PSARVUP and followed a postoperative protocol of anal dilation (Fig. 1). A retrospective review of patients with anorectal malformation (ARM) who underwent a primary PSARP or PSARVUP from February 2016 to October 2021 was performed. Data collected included patients' demographics, type of ARM, age at the time of operation, postoperative complications, with emphasis on whether there were any strictures or any difficulties during dilations, and on follow-up. During the surgical repair, emphasis was placed on preserving the blood supply of the bowel and performing a tension-free bowel-to-skin anastomosis. Eighty-four patients met the inclusion criteria. Forty-four patients were females: 21 recto-perineal fistula, 12 cloaca, 9 recto-vestibular fistula, one imperforate anus without fistula, and one patient had a complex anorectal and vaginal malformation with an anal stricture and a rectovaginal fistula. Forty patients were males: 14 recto-perineal fistula, 11 recto-urethral bulbar fistula, 6 recto-urethral prostatic fistula, 6 imperforate anus without fistula, and 2 bladder neck fistula. One patient had an anal stenosis with sacral agenesis, without a presacral mass. Patient ages ranged from 0 to 79months (mean 7.5months, median 5months) at the time of surgery. Follow-up time ranged from 7 to 73months (mean 38months, median 35months). No patient suffered of a postoperative anal stricture. Six patients suffered of a rectal prolapse that required a surgical repair. Post-operative anal stricture after PSARP and PSARVUP can be avoided with proper surgical technique and postoperative care. Namely, by preserving adequate blood supply of the bowel and avoiding tension at the anoplasty, and by adhering to a structured protocol of anal dilations.

Prenatal Diagnosis and Management of Isolated Recto-Urethral Prostatic Fistula: A Case Report

BackgroundRecto-urethral prostatic fistula (RUPF) is a rare form of anorectal malformation (ARM). Its prenatal diagnosis and management with a minimum consequence are challenging. This study aimed to present diagnostic and therapeutic modalities in a patient with RUPF.Case reportA 32-year-old pregnant woman with no relevant medical or surgical history at 27 weeks of gestation was referred to our department of pediatric surgery. Prenatal ultrasound showed loop dilatations and enterolithiasis. Fetal magnetic resonance imaging (MRI) imaging confirmed the diagnosis of ARM and suggested the presence of a recto-urinary fistula. There was no other associated malformation. Parents decided on the continuation of pregnancy after counseling. A 2300 g male was born at 37 weeks of gestation in February 2019. Colostomy followed by laparoscopic pull-through were performed. Expectations of the physician and parents were met after a one-year follow-up period.ConclusionFetal MRI had the potential to diagnose ARM more accurately than ultrasound. Moreover, laparoscopic pull-through was safe and feasible.

Can complex surgical interventions be standardized? Reaching international consensus on posterior sagittal anorectoplasty using a modified-Delphi method

Background/PurposeIn an effort to standardize educational experience, address future physician shortages, and improve quality of care to patients, many surgical specialties are discussing how to maximize exposure to index cases. One solution being explored is telementoring, which requires a well-developed educational curriculum with intraoperative objectives. The American College of Surgery Telementoring Task Force selected anorectal malformation and posterior sagittal anorectoplasty (PSARP) for the repair of imperforate anus as the initial educational focus for this pilot. The purpose of this study was to obtain international consensus on intraoperative learning objectives for a complex surgical procedure. MethodsA multidisciplinary team of medical educators and pediatric surgery experts created an outline of essential curricular content and intraoperative learning objectives for PSARP in three clinical scenarios. Twelve international subject matter experts were identified meeting strict inclusion criteria. Intraoperative checklists were revised using the modified-Delphi process. ResultsAfter five rounds of modifications to the intraoperative checklists, international consensus was achieved for three different clinical scenarios requiring a PSARP: perineal or vestibular fistula, low prostatic fistula, and bladder neck fistula. ConclusionsA modified-Delphi approach was successful in generating guidelines for surgical techniques that can be used to standardize intraoperative teaching and expectations for trainees. Type of studyDiagnostic study Level of evidenceLevel V (expert opinion)

Neonatal Ultrasound for Anorectal Malformations in Male Newborns Without Perineal Fistula: A Good Diagnostic Tool for A Safe One-Staged Surgery

Background/Purpose: The standard neonatal approach for a male newborn with an anorectal malformation (ARM) and no perineal fistula remains the opening of a diverting colostomy. Here we describe radiological improvements in neonatal ultrasound (US) that characterize the recto-urinary fistula and allow a direct anorectal reconstruction. Material and Methods: This is a descriptive report of radiological findings in neonatal ultrasound in all newborn male patients with an ARM, no perineal fistula and no colostomy, recruited over a 6-year period. A paediatric radiologist actively looked for recto-urinary fistulas and their relation to anatomical landmarks. These findings, along with the clinical status and associated anomalies, were considered to indicate a single-staged procedure. Results: From 28 neonates with ARM only three met the inclusion criteria. The first 2 cases showed a bulbar and prostatic fistula in US but with associated malformations and benefited from a colostomy. The third baby presented a bulbar fistula in the US, normal sacrum and no lifethreatening malformations and benefited from a singlestaged procedure. Conclusions: Neonatal perineal US can give the same anatomical information than the distal colostogram and leads to a safe single-staged procedure in expert teams, if there is a lack of associated life-threatening malformations.

Fact or myth? The long shared common wall between the fistula and the urethra in male anorectal malformation with urethral bulbar fistula.

It has long been considered surgical dogma that the length of the shared common wall (CW) between a fistula and the urethra in males with anorectal malformation (ARM) and rectourethral bulbar fistula (RUBF) is considerably longer than in males with ARM and rectourethral prostatic fistula (RUPF). This belief has led surgeons who perform laparoscopic-assisted anorectoplasty (LAARP) for RUPF to avoid LAARP for RUBF for risk of potential injury to the urethra or incomplete removal of the fistula. In this study, we compared CW between RUBF and RUPF using distal colostography (DCG) and direct intraoperative measurements. DCG of rectourethral fistula patients (n = 63; RUBF: n = 44; RUPF: n = 19) were used to measure CW retrospectively. Results were expressed as a ratio of the height of L4; i.e., CW:L4. If less than 0.7, the CW was classified as being "short"; if 0.71-1.4, as being "medium"; and if greater than 1.41, as being "long". CW that could not be measured was classified as indeterminate. 24 of these patients also had CW measured intraoperatively during LAARP as previously described. The results obtained using both techniques were also compared. Surprisingly, CW:L4 in RUBF patients was short in 47.7%, medium in 27.3%, long in 20.5%, and indeterminate in 4.5% on DCG, equivalent to mean lengths of 7mm, 8.5mm, and 10.3mm obtained using direct intraoperative measurement for short, medium, and long CW:L4 categories, respectively. CW:L4 in RUPF was short in 73.6%, medium in 10.5%, and long in 5.2% on DCG, while mean intraoperative measurements were 5mm, 7mm, and 10mm, respectively. Differences in CW measured intraoperatively were not significantly different between RUBF and RUPF (p = NS). From our findings, 47.7% of CWs in RUBF were short using two independent methods, with only 20.5% being long. Thus, LAARP should be considered actively for treating selected RUBF cases and not be excluded on the basis of CW length.

One-Stage Laparoscopic-Assisted Anorectoplasty for Neonates with Anorectal Malformation and Recto-Prostatic or Recto-Bulbar Fistula According to the Krickenbeck Classification.

Congenital recto-urethral fistula (RUF) is the most common form of anorectal malformations (ARMs) found in boys. The aim of this study is to review our experience with one-stage laparoscopic procedure in the management of ARMs with recto-prostatic fistula and recto-bulbar fistula. Seventeen boys with congenital RUF who underwent one-stage laparoscopy-assisted anorectoplasty (LAARP) between July 2012 and June 2015 were retrospectively in the study. All patients successfully underwent one-staged laparoscopic surgery without conversion. The recto-prostatic urethral fistula was encountered in 6 patients and recto-urethral bulbar fistula in 11 patients. The mean age at the time of surgery was 46.2 hours with mean length of hospital stay being 10.6 days. The operative times for the recto-urethral prostatic fistula and recto-urethral bulbar fistula were similar (128.2 versus 122.4 minutes, P = .091). Intraoperative blood loss was minimal. No injury to the urethra or vas deferens. The urethral catheter was removed on postoperative day 10. No one lost to follow-up. The median follow-up period was 2.6 years (range: 2-4 years). No recurrent fistula or urethral diverticulum was detected according to the voiding cystourethrography and pelvic MRI at 1 year. One-stage LAARP is safe and effective for neonates with recto-prostatic fistula and recto-bulbar fistula. It provides an alternative method to rectify the ARMs with recto-prostatic fistula and recto-bulbar fistula without colostomy.

One stage correction of anorectal malformations in newborns.

The retrospective analysis of case histories of 35 infants (19 boys, 16 girls), treated in the department of reconstructive surgery of Dnipropetrovsk center of mother and child health in the period 2008-2013 was done. All the patients underwent one-stage treatment of anorectal malformations in neonatal period. Surgery was performed in the first 48 hours of life. Body weight of infants ranged from 2,8 to 4,4 kg (average weight 3,2 kg). Among related conditions there were observed vesico-ureteral reflux (VUR) – in 11 (31,4%), VATER association - in 6 (17.1%), malformations of the spine – in 18 (51,4%), of the heart – in 2 (5,7% ). During cystoscopy fistula in the urinary system was revealed in 16 boys. Surgical treatment was carried out by the posterior sagittal anorectoplasty (PSARP) by A.Pena. 2 patients additionally underwent laparotomy. Among 16 patients with fistula in the urinary system, prostatic urethra fistula was revealed in 14, bladder neck fistula – in 2. Children were discharged from the hospital 2 weeks after surgery. All the children re­ceived anti­biotics due to the presence of VUR. After 1 month after surgery VCUG was performed. Long-term results were studied for a period of 10 to 24 months. All patients had VUR without evidence of hydronephrosis. In the period of 3-6 months after surgery 2 patients presented anal stenosis due to violation of dilatation. The evaluation results in the late period (10-24 months after surgery) noted the presence of normal stool 2-3 times a day, 3 children had periodic con­stipations treated by diet. Available merits of the described method: only one operation and general anesthesia is per­for­med, no risk of prolonged contamination by pathogenic flora of the urinary system through the fistula, potential risk of complications of laparotomy and colostomy decreases, fistula visualization in cystoscopy allows to avoid the X-ray.

Laparoscopic approach in the management of anorectal malformations.

Seventeen years have passed since the first description of the laparoscopic approach for anorectal malformation and approximately 68 articles have been published on the subject. In this review article, we aim to describe the advantages as well as the indications and contraindications of this approach when dealing with each specific type of anorectal malformation, according to what has been described in the literature and to our own experience. The ideal and undisputable indication for laparoscopy remains for cases in which the abdomen needs to be entered to repair the malformation. Only 10% of male patients with anorectal malformation are born with a recto-bladder neck fistula that requires an abdominal approach, this represents an ideal indication for laparoscopy. In females, only the complex cloacae with a common channel length greater than 3 cm are the ones that require a laparotomy; they represent about 30% of the cloacae. However, the repair of this type of cloacae also requires sophisticated and technically demanding maneuvers that have never been done laparoscopically. In cases of recto-urethral prostatic fistulas the malformation can be repaired either way: laparoscopically or posterior sagitally. In all other malformations: recto-perineal fistula, recto-urethral bulbar fistula, anorectal malformation without fistula, rectal atresia, recto-vestibular fistula; no justification for laparoscopy could be found; and in some cases, laparoscopy is contraindicated. In the published reports, there is no evidence supporting the idea that laparoscopic repair results in better functional results when compared with non-laparoscopic operation; there is a tendency to omit information relevant to bowel control such as the characteristics of the sacrum and the presence or absence of tethered cord; and most authors do not compare results between comparable malformations.

Hypermethylation of SHH in the pathogenesis of congenital anorectal malformations

ObjectiveThis study sought to examine promoter methylation and expression of the identified sonic hedgehog (SHH) gene in terminal rectal tissues of children with congenital anorectal malformations (ARMs). MethodsTissue samples from the terminal rectum of pediatric patients with ARMs (five cases each of high and intermediate malformation — two cases of rectovesical fistula, two cases of rectourethral prostatic fistula, one case of cloaca with >3cm common channel, four cases of rectourethral bulbar fistula and one case of imperforate anus without fistula, respectively, and ten cases of low malformation — five cases of perineal fistula and five cases of vestibular fistula, respectively), and patients with non-gastrointestinal tract malformation (six cases, anal fistula) were collected and divided into three groups: high-intermediate ARM (ARMhi-int), low ARM (ARMlo), and control (Cont.). Real-time RT-PCR was used to detect mRNA expression levels of the verified differentially methylated gene SHH, and bisulfite genomic sequencing was performed to evaluate DNA methylation in the SHH promoter region. ResultsThe average methylation levels of the SHH promoter were significantly higher in ARMhi-int (0.850±0.030, P=0.0036) and ARMlo (0.540±0.053, P=0.0087) groups than in Cont. group (0.280±0.032). SHH mRNA expression levels were lower in ARMhi-int (0.340±0.015, P=0.0065) and ARMlo (0.530±0.042, P=0.0156) groups than in Cont. group (0.870±0.046). The average methylation levels of the SHH promoter were higher in ARMhi-int group than in ARMlo group (0.850±0.030 vs. 0.540±0.053, P=0.0095), while SHH expression was significantly reduced in ARMhi-int group compared to ARMlo group (0.340±0.15 vs. 0.530±0.042, P=0.0252). The methylation levels of the SHH promoter in ARMhi-int group were negatively correlated with SHH gene expression (r=−0.89, P<0.01). ConclusionsThe SHH gene, which plays a major role in the development of the anorectum and enteric nervous system, is hypermethylated at its promoter, and this is correlated with low levels of SHH gene expression. This epigenetic modification may therefore be responsible for the observed changes in SHH expression, which could in turn underlie the pathogenesis of congenital ARMs.

Laparoscopically Assisted Anorectoplasty Using Perineal Ultrasonographic Guide

Background/Purpose : As minimal invasive surgery,laparoscopy assisted anorectal pull-through has been reported with new devices. However, it is not easy to create an accurate pull-through canal (PTC), because of the narrow space between the urethra and puborectal sling. The authors describe a new method employing perineal ultrasonography.Methods: The rectourethral prostatic fistula was dissected laparoscopically. Externally, electrostimulation identified the center of the muscle contraction, over which a 1.2 cm of skin incision was made, and the lower part of PTC was created by hemostat forceps guided by electrostimulation. An ultrasonographic probe applied to the perineum demonstrated the urethra, and the forceps was advanced behind the urethra into the pelvic cavity using the ultrasonographic guide. Anorectal pullthrough was performed following dilatation of the PTC with dilators.Results: The authors applied this procedure in 9 cases of male high anomalies. Surgical damages to the urethra, the levator and vertical muscles were not encountered. Postoperative MRI demonstrated a good location of the rectum, and fluoroscopic study showed a good anterior angulation and intact contraction and relaxation of those muscles.Conclusion: The combination of laparoscopic dissection, pinpointing the center of anal sphincter by electrostimulation and identification of the urethra by ultrasonographic images from the perineum facilitated creation of appropriate PTC in the muscle complex.DOI: http://dx.doi.org/10.3329/jpsb.v1i1.19447

Esophageal atresia in patients with anorectal malformations.

The presence of esophageal atresia (EA) in patients with an anorectal malformation (ARM) is well known. The purpose of this work is to find out the most common type of ARM associated to EA and the functional prognostic implication of this association, which has not been described in previous publications. We reviewed our database for demographic, functional, and associated anomalies data in our patients with EA and ARM, and then compared them with those of our general series of ARM without esophageal atresia. Out of 1,995 ARM patients, 167 had a concomitant EA (8.3 %). Prostatic fistula was the most common type of defect in the male EA patients (45.9 %) and cloacas were on the female group (57.9 %). EA patients had worse bowel (47 vs. 67 %) and urinary control (56.6 vs. 79.4 %) when compared to the general series (GS). Functional prognosis was significantly worse in cloacas and in patients subjected to re-operations (p < 0.001). EA patients had a 0.52 average sacral ratio and in the GS was 0.65 (p < 0.001). EA patients had a significantly higher incidence of tethered cord (32.3 vs. 17.6 %), cardiac anomalies (32.3 vs. 22.5 %) including VSD (12.5 vs. 4.5 %), hydronephrosis (36.5 vs. 15.4 %), absent kidney (26.3 vs. 10.5 %), duodenal atresia (7.7 vs. 1.7 %), vertebral anomalies (28.1 vs. 14 %), extremity defects (11.3 vs. 3.1 %), tracheal anomalies (6.5 vs. 0.4 %), and developmental delay (5.9 vs. 1.4 %). The presence of esophageal atresia in ARM patients has a significant, probably coincidental, impact on bowel and urinary control. This association is also related with worse types of ARM defects and with more severe associated anomalies. This association should increase the awareness on the provider in terms of what to expect on functional prognosis and a throughout search for associated anomalies.

The influence of anorectal malformations on fertility: a systematic review.

This systematic review aims to give an overview of available evidence concerning the influence of anorectal malformations (ARM) on fertility. We conducted a search in PubMed, EMBASE and Cochrane Library conformed to the PRISMA standards. All studies reporting on fertility and ARM were included. 2,905 studies were identified. Based on title, abstract and full text, nine articles on 429 patients remained to answer the research question. Childbirth rate was the only reported outcome parameter to describe fertility. An overall childbirth rate of 27 % (range 0-57 %) was found. Mean age at time of study ranged from 23 to 35 years. There was no statistical significant difference in childbirth rate between female and male patients, based on seven studies (p = 0.45). Patients with a more complex type of ARM (imperforated anus without fistula, rectourethral bulbar and prostatic fistulas, rectobladderneck fistulas and cloacal malformations) had a lower childbirth rate compared to healthy controls, whereas in patients with a less complex ARM (rectoperineal or rectovestibular fistula) the childbirth rate was similar to healthy controls. Patients with a more complex type of ARM had a significant lower childbirth rate than patients with a less complex type of ARM (18 vs 47 %, respectively) (p = 0.0001). When further dividing these patients by gender, this difference was only seen in female patients (p = 0.04). In patients with a more complex type of ARM a lower childbirth rate was found compared to healthy controls and patients with a less complex type of ARM. The latter was only seen in female patients. However, conclusions concerning fertility in ARM patients have to be taken with caution due to limited quality of the studies. Further investigation is recommended.

Laparoscopic-assisted PSARP — the advantages of combining both techniques for the treatment of anorectal malformations with recto-bladderneck or high prostatic fistulas

AimThe aim of this study was to present an alternative way to use both the posterior sagittal approach combined with laparoscopy for the repair of select cases of anorectal malformation (ARM). MethodsThe 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. The posterior sagittal incision we believe made the perineal portion safer, allowing for rectal tapering when necessary, and for accurate placement of the rectum, anchored in the center of the sphincter. ResultsThere were 15 children (recto-bladderneck fistula, n=13 and recto-prostatic fistula, n =2) in this series. There were no urethral injuries, posterior urethral diverticula, or rectal strictures. A laparotomy was needed in two children in order to mobilize a very high rectum. Follow-up ranged from 3months to 10years. Clinical results were consistent with our published series for male patients with these types of defects: 5 are fecally incontinent (3 are clean with a bowel management program), 1 is fecally continent, and 9 are too young to assess. Four children suffered rectal mucosal prolapse. ConclusionThe combination of laparoscopy and PSARP represents a useful technical alternative that allows for a safe reconstruction in cases of ARM with recto-bladderneck and in selected high prostatic fistulas.

High anorectal malformation in a five-month-old boy: a case report

IntroductionAnorectal malformation, one of the most common congenital defects, may present with a wide spectrum of defects. Almost all male patients present within first few days of life.Case presentationA five-month-old baby boy of Indian origin and nationality presented with anal atresia and associated rectourethral prostatic fistula. The anatomy of the malformation and our patient's good condition permitted a primary definitive repair of the anomaly. A brief review of the relevant literature is included.ConclusionDelayed presentation of a patient with high anorectal malformation is rare. The appropriate treatment can be rewarding.

Clean Intermittent Catheterisationcic in Boys with Abnormal Urethra is Problematic at Adolescence

Purpose Clean intermittent catheterisation (CIC) is a treatment alternative in boys with bladder dysfunction due to congenital urethral anomalies. Starting CIC has been shown to be easiest during the infant year. In this study boys with abnormal urethra and normal urethral sensitivity treated with CIC has been followed through puberty, and problems with this treatment strategy was evaluated. Material and Methods 22 boys in whom CIC was started early were followed to 14 - 22 years of age. Diagnoses were posterior urethral valves (18), ARM with prostatic fistula (2), prune belly syndrome (1) and ectopic ureterocele (1). CIC was started at median age of 0.7 years (range 0.3-6.6). Results 5/22 boys ended CIC at median age 5 years (range 3-7) because of normalisation of bladder function. 13/22 boys ended CIC at median age 14 years (range 12-16) because of difficulties to introduce the catheter in combination with painful catheterisations. 3 boys developed strictures of the bulbar urethra. Internal urethrotomy was primarily done, but in 2 boys open resection was necessary. At present 3 of the 13 boys with urethral problems catheterise via a Mitrofanoff stoma, 3 have resumed CIC and 7 boys are without CIC despite of need. 4/22 boys are still on CIC without major problems. Conclusion CIC is feasible in boys with abnormal urethras and normal urethral sensitivity through childhood. When reaching puberty catheterisation problems are common and acquired strictures were seen. A catheterisable stoma at an early age should be an option, which could be used both for emptying during day and for night drainage of the bladder.

MP-01.24: Prostatic fistula to perineum and rectum: a vexing problem

MP-01.24: Prostatic fistula to perineum and rectum: a vexing problem

Laparoscopically assisted anorectoplasty using perineal ultrasonographic guide: A preliminary report

Background/Purpose As minimal invasive surgery, laparoscopically assisted anorectal pull-through has been reported with new devices. However, it is not easy to create an accurate pull-through canal (PTC) because of the narrow space between the urethra and puborectal sling. The authors describe a new method using perineal ultrasonography. Methods The rectourethral prostatic fistula was dissected laparoscopically. Externally, electrostimulation identified the center of the muscle contraction, over which a 1.2-cm skin incision was made, and the lower part of PTC was created by hemostat forceps guided by electrostimulation. An ultrasonographic probe applied to the perineum demonstrated the urethra, and the forceps was advanced behind the urethra into the pelvic cavity using the ultrasonographic guide. Anorectal pull-through was performed after dilatation of the PTC with dilators. Results The authors applied this procedure in 5 cases of male high and intermediate anomalies. Surgical damages to the urethra and the levator and vertical muscles were not encountered. Postoperative fluoroscopic study demonstrated good anterior angulation and intact contraction and relaxation of those muscles. Conclusion The combination of laparoscopic dissection, pinpointing the center of anal sphincter by electrostimulation, and identification of the urethra by ultrasonographic images from the perineum facilitated creation of appropriate PTC in the muscle complex.