Rectourethral Bulbar Fistula Research Articles

Experience with laparoscopic-assisted anorectal pull-through in 25 males with anorectal malformation and rectourethral or rectovesical fistulae: postoperative complications and functional results

IntroductionLAARP (laparoscopic-assisted anorectal pull-through) has become an established operation for anorectal malformation (ARM) with rectourethral or rectovesical fistula. The aim of this study was to review post-LAARP operation complications and midterm functional results. MethodsBetween 2003 and 2010, we performed 28 LAARPs in ARM patients with rectourethral or rectovesical fistula. We retrospectively analyzed the clinical outcomes in 25 male patients with rectourethral or vesical fistulae. ResultThe mean age of the patients at the time of LAARP was 2.7±1.4months. The most common ARM type was rectoprostatic urethral fistula (n=16). Few immediate postoperative complications (urinary tract infection (1), ileus (1), and one case of pneumonia) occurred. Rectal mucosal prolapse developed and was excised 6months later in 13 (52%) patients. Urethral diverticulum occurred in one patient with a rectobulbar urethral fistula. Immediate postoperative high rectal tone developed in six patients during the early study period (2003–2004). Six of the 12 patients older than 3years had voluntary bowel movement and no soiling. ConclusionLAARP was a safe procedure. Shorter dissection of rectum in the intra-abdominal space may be helpful in preventing rectal mucosal prolapse. Intermittent rectal tube insertion may be useful for the patient with high rectal tone in the immediate postoperative period. LAARP is not recommended for the bulbar fistula with a long common wall.

Temporary umbilical loop colostomy for anorectal malformations

Transumbilical surgical procedures have been reported to be a feasible, safe, and cosmetically excellent procedure for various pediatric surgical diseases. Umbilical loop colostomies have previously been created in patients with Hirschsprung's disease, but not in patients with anorectal malformations (ARMs). We assessed the feasibility and cosmetic results of temporal umbilical loop colostomy (TULC) in patients with ARMs. A circumferential skin incision was made at the base of the umbilical cord under general anesthesia. The skin, subcutaneous tissue, and fascia were cored out vertically, and the umbilical vessels and urachal remnant were individually ligated apart from the opening in the fascia. A loop colostomy was created in double-barreled fashion with a high chimney more than 2 cm above the level of the skin. The final size of the opening in the skin and fascia was modified according to the size of the bowel. The bowel wall was fixed separately to the peritoneum and fascia with interrupted 5-0 absorbable sutures. The bowel was opened longitudinally and everted without suturing to the skin. The loop was divided 7 days postoperatively, and diversion of the oral bowel was completed. The colostomy was closed 2-3 months after posterior saggital anorectoplasty through a peristomal skin incision followed by end-to-end anastomosis. Final wound closure was performed in a semi-opened fashion to create a deep umbilicus. TULCs were successfully created in seven infants with rectourethral bulbar fistula or rectovestibular fistula. Postoperative complications included mucosal prolapse in one case. No wound infection or spontaneous umbilical ring narrowing was observed. Skin problems were minimal, and stoma care could easily be performed by attaching stoma bag. Healing of umbilical wounds after TULC closure was excellent. The umbilicus may be an alternative stoma site for temporary loop colostomy in infants with intermediate-type anorectal malformations, who undergo radical anorectoplasty via a non-abdominal approach.

Transvesical resection of a mucocele after laparoscopically assisted anorectal pull-through for imperforate anus with rectobulbar urethral fistula

Mucocele formation is a rare complication after imperforate anus repair. Abdominal cyst enucleation or resection, transrectal resection by a posterior sagittal approach, and perineal cyst resection are the standard surgical options. The authors report the first patient who underwent transvesical mucocele resection.

The morbidity of constipation in patients with anorectal malformations

Background Constipation in anorectal malformations (ARM) is extremely common, particularly in the lower types. Failure to adequately treat it can lead to significant morbidity. Methods From our series of over 2000 patients with ARM, we reviewed 398 with good prognosis for bowel control and a tendency toward constipation; rectoperineal fistula (63), rectovestibular fistula (114), rectobulbar urethral fistula (104), imperforate anus with no fistula (46), rectal atresia or stenosis (9), and cloaca with a common channel below 3 cm (62). Those lost to follow-up, not yet toilet-trained (<3 years old), or with poor prognostic features were excluded. We compared morbidities in patients we operated on and managed primarily (group A, n = 268) to those managed at other institutions who suffered from constipation or incontinence and were referred to us for treatment (group B, n = 130). Those we managed primarily were subjected to an aggressive senna-based laxative program, started after their primary repair or after colostomy closure. Results Morbidities associated with constipation were higher in the referral group and included fecal impaction (7.8% vs 38.5%), overflow pseudoincontinence (4.9% vs 33.8%), and megacolon (14.6% vs 54.6%). A loop or transverse colostomy (4.9% vs 9.2%), stoma or anorectal stricture, or a stenotic fistula (2.2% vs 28.5%) were contributing factors. Adequate laxative treatment with, in certain cases, resection of a megarectosigmoid (2.6% vs 23.1%) enabled many pseudoincontinent children to achieve bowel control (reported previously). Unneeded colorectal biopsies (1.9% vs 16.2%), Hirschsprung's-type pullthroughs (0% vs 3.1%), and, in retrospect, unneeded antegrade continent enema procedures (0% vs 3.1%) were higher in Group B. Overall, 19.8% of Group A and 66.2% of Group B experienced constipation-related morbidities. Conclusion The morbidity of constipation in ARM includes fecal impaction, megacolon, incontinence, and performance of unneeded surgeries. Inadequate treatment, the type of the original colostomy, and postoperative anal or stomal stricture as well as stenotic fistulae were key contributing factors. Children with ARM and good prognosis for bowel control are at the greatest risk for severe constipation and its consequences. With recognition and aggressive, proactive treatment, we have found that these morbidities can be reduced.

Management of male H-type anorectal malformations

H-type anorectal malformations (ARM) are extremely rare in males. Herein, we have described our experience of managing this variety. From September 1993 to February 2009, seven boys with H-type ARM were managed in the Department of Pediatric Surgery, Chittagong Medical College and Hospital, Chittagong, Bangladesh. Clinical features, operative procedures and outcomes were analyzed. Age ranged from 1 day to 4 years. The passage of meconium was seen in urine of four boys, through ectopic openings in the perineum in three boys. One patient had a round worm passing through an ectopic opening. Three boys' perineum showed meconium dots/streak along scrotal raphe. Anus was absent in all. Two patients had rectopenilurethral (RPU) and rectoscrotal (RS) fistula; two boys had anoscrotal and anoperineal fistula; one boy had pinhole anus with RS and RPU fistula. One boy had rectoperineal and RS fistula. One patient had rectobulbar urethral fistula with meconium filled chamber between the two hemiscrotum. Two boys had associated anomalies. Five boys had primary procedure with anterior sagittal approach-anoplasty (ASAP) and anorectoplasty (ASARP). Two patients had pelvic colostomy and ASARP in one and PSARP in one. One patient died postoperatively. One boy developed anal stenosis and needed redo. Five children have regular bowel movements and they are growing well. Thorough clinical examination may identify the anatomical variations of male H-type ARM, and for the treatment of which primary ASAP or ASARP gives good results.

Endoscopy-Assisted Laparoscopic Excision of Rectourethral Fistula in a Male with Imperforate Anus

We report a surgical technique that we developed to facilitate complete excision of rectourethral fistula (RUF)in male patients with imperforate anus (IA). A 6-month-old boy with rectobulbar urethral fistula (bulbar-RUF)had laparoscopic repair of IA. During laparoscopic dissection of the RUF, a fine flexible endoscope was inserted into the rectum through an opening made in the anterior rectal wall. Endoscopy of the rectum allowed the level of laparoscopic dissection to be observed intraluminally, allowing the bulbar-RUF to be excised exactly at its distal end. He is well after follow-up of 9 months with no evidence of residual RUF on radiologic investigations.We have since used this technique to treat another IA patient with prostatic-RUF successfully.

A case of rectal atresia associated with rectobulbar urethral fistula

Rectal atresia is a rare condition in which the anus and sphincter muscles are normally developed, with usually no fistulous communication with the urinary tract. An unusual case of rectal atresia associated with recto-bulbar urethral fistula treated by a combination of colo-anal anastomosis and mucosal proctectomy via a posterior sagittal approach is reported for the first time.

Anal agenesis with rectobulbar fistula.

Anal agenesis with a rectobulbar urethral fistula is an uncommon type of male imperforate anus. Six cases are presented with a review of the main features of the disorder, the possible embryologic origin, and the surgical management.