Rectoprostatic Urethral Fistula Research Articles

Erudition from primary posterior sagittal anorectoplasty for anorectal malformations over two decades.

Perioperative and early post-operative outcomes of Primary Posterior sagittal anorectoplasty (P-PSARP) were evaluated. Retrospective analysis of cases who underwent P-PSARP from 2004 to 2019 was done. Perioperative care, management, complications, voluntary bowel movement, soiling and constipation, graded by Krickenbeck criteria were studied. One hundred fifty six patients (134 girls) underwent P-PSARP at median age of 5months (3months to 14years) in girls and 5(1-10) days in 21 boys. One male cloaca was operated at 5months age. Of 20 boys, 5, 8, 4, 3 had rectobulbar urethral fistula, rectoprostatic urethral fistula, bladder neck fistula and male cloaca. Girls had vestibular fistula, rectovaginal fistula, vulval anus, anterior ectopic anus, pouch perineal fistulae and posterior anus with H type fistula in 114, 7, 6, 5, 1 and 1. Complications included wound infection, excoriation, oedema, mucosal prolapse, anal stricture, anal retraction and mortality in 6, 4, 5, 4, 4, 1 and 1, respectively. 35/155(12 neonates) required postoperative dilatations for 5(1-12) months. At follow-up, 96/114(84.2%) had voluntary bowel movements. 46/155 (29.7%) and 9/155 had constipation and soiling. 32:14:0 had grade 1:2:3 constipation, treated with diet (grade 1) and laxatives (grade 2) respectively. 4:3:2 had grade 1:2:3 soiling for initial 3months, treated with bowel management programme. P-PSARP is feasible, subject to proper case selection and good perioperative care, once learning curve is achieved.

Prevalence and Factors Associated with Post-operative Strictures in Anorectal Malformations

Objective: Rectal strictures are a serious complication following operation for anorectal malformations (ARM). The purpose of this study was to determine the factors affecting rectal strictures following surgical treatments for ARM. Materials and Methods: Retrospective chart reviews of 204 patients with ARM who underwent surgical treatment at Siriraj Hospital between January 2003 and December 2019 were carried out. Results: Overall, the prevalence of post-operative rectal stricture was 19.6% (40/204). The higher types of ARM had higher rectal stricture rates. In low type ARM, the stricture rate following surgery for perineal fistula, vestibular fistula was 4.1% and 14.7%, respectively. Recto-bulbar urethral fistula and recto-prostatic urethral fistula had stricture rates of 19.2% and 26.7%, respectively, but in higher types, the stricture rates were above 70%. Complications such as wound infection, dehiscence, retraction, colonic necrosis and recurrent fistula all affected the post-operative stricture rate (p = 0.029, p = 0.01, p = 0.01, p = 0.042 and p = 0.002, respectively). The operation for low type ARM using local tissue flap, such as YV and cutback anoplasty, had low complications. More complicated operations were performed for higher type ARM. The higher the complication rate, the higher the post-operative rectal stricture. Routine rectal dilatation by parents seemed to prevent rectal strictures (p = 0.056). The surgical treatments for rectal strictures composed of 57.5% anoplasty, 17.5% PSARP, 15% abdo-assisted pull-through and 10% abdo-assisted PSARP. Conclusion: Post-operative rectal stricture occurred because of complications following complicated operations for high type ARM. A meticulous operative technique is crucial.

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.

Laparoscopic-Assisted Modified Posterior Sagittal Anorectoplasty for Rectobulbar Urethral Fistula of Anorectal Malformation: A Prospective Study.

Introduction:Laparoscopic anorectoplasty (LAARP) is useful for the management of rectoprostatic urethral fistula (RPUF), due to easier rectal mobilization, avoidance of posterior sagittal muscular incision, and shorter hospital stay. However, its role in rectobulbar urethral fistula (RBUF) is still debated as there is a chance of urethral diverticulum (UD), due to incomplete dissection. Laparoscopy-assisted modified posterior sagittal anorectoplasty (LAMPSARP) utilizes advantages of LAARP combined with fistula dissection using small sagittal incision preserving puborectalis. The present study compares the results of LAMPSARP with LAARP for correction of RBUF associated with anorectal malformations (ARMs).Materials and Methods:All male ARM with RBUF presenting in a tertiary center in Central India (January 2014–January 2016) were included. Low male ARM, RPUF, rectovesical fistula, and congenital pouch colon were excluded. They were randomized into LAARP and LAMPSARP groups. Complications were assessed in terms of anal stenosis, mucosal prolapse, and UD. Kelly's scoring and Krickenbeck scoring were used to assess continence, and visible anal cosmesis scale (VACS) was used to assess wanal cosmesis. Results were statistically analyzed using a comparison of means and 2 × 2 contingency tables.Results:Fifty-six colostomized patients with RBUF (26 LAARP, 30 LAMPSARP) were included. Mean operative duration in the LAARP group and LAMPSARP group was 42 ± 10 min and 56 ± 12 min, respectively (P < 0.0001). On mean follow-up of 4.5 years, mucosal prolapse (53.9%) and UD (15.38%) were significantly higher in LAARP group, while anal stenosis was similar. All three, Kelly's score, Krickenbeck score, and VACS, were better (P < 0.05) in the LAMPSARP group.Conclusion:Laparoscopy-assisted modified posterior sagittal approach is better for RBUF and offers better surgical outcome.

To Study the Outcome of Posterior Sagittal Anorectoplasty in Anorectal Malformations

Aim: To assess the effectiveness of posterior sagittal anorectplasty for the repair of anorectal malformations in terms of postoperative complications and functional outcomes. Study design: Descriptive prospective study. Place and duration of study: Sahiwal Teaching Hospital, Sahiwal. From 1st January 2016 to 31st December 2019. Methodology: Forty-two children with high/intermediate anorectal malformations, who underwent posterior sagittal anorectoplasty, were included in the study. Patients with low variety anorectal malformations, recto vestibular/ano vestibular fistula, persistent cloaca and patients with sacral dysraphism, spinal dysraphism, myelomeningocele spina bifida occulta and menifesta were excluded. Demographic information included age, gender, weight, type of anorectal malformation, type of surgery performed, operation time and hospital stay. Immediate post-operative complications were also noted. Bowel habits, constipation and faecal incontinence were evaluated in all patients during the follow up period. Results: Thirty-one (73.80%) were males and 11(26.19%) were females and mean age was 1.72 years. The mean weight at the time of operation was 11.00 kg. High variety anorectal malformations were 14(33.33%) and intermediate were 28(66.66%). Rectourethral fistula 25(59.52%) was most common variety seen in males. Recto bulber urethral fistula in 17(40.47%) and recto prostatic urethral fistula in 8(19.04%) patients were seen. Anal agenesis without fistula 7(16.66%) was most common anomaly in females. Overall complication rate was 15(35.71%). Constipation 11(26.19%) was most common post-operative complication. True fecal incontinence was seen in 3(7.14%) patients. Strong and effective squeeze of anal sphincter was seen in 39 (92.85%) patients and satisfactory bowel habits were present in 37 (88.08%) patients. Conclusion: Posterior sagittal anorectplasty is a useful procedure in the management of high/intermediate anorectal malformations, precise identification and reconstruction of muscle complex result in good anatomical and functional outcome. Immediate post-operative complication rate is also low. Keywords: Anorectal malformations, Posterior Sagittal Anorectoplasty, Postoperative complications, Functional outcomes

Prevalence and Association of Occult Spinal Dysraphism with Anorectal Malformation

Background: Anorectal malformation (ARM) is associated with occult spinal dysraphism (OSD). The guideline for screening for OSD in patients with ARM is still controversial. Objective: 1) To evaluate the prevalence of OSD in each type of ARM and to elucidate which types of ARM should be screened for underlying OSD. 2) To compare the methods used in radiologic screening for OSD, such as plain lumbosacral X-ray, spinal ultrasound (U/S), and spinal magnetic resonance imaging (MRI). Materials and Methods: The medical records of all patients with ARM treated at Siriraj Hospital between 2006 and 2016 were reviewed. Spinal dysraphism screening with lumbosacral X-ray, U/S, or MRI were performed depending on the surgeon’s request. Associated urinary tract anomalies were noted. Data of the surgical treatments, outcomes, and complications of treatments were collected. Results: Among the 204 ARM patients treated, 150 patients were screened for OSD, involving 150 lumbosacral X-ray, 65 U/S, and 39 MRI. The prevalence of OSD (n=33) in all types of ARM was 16.2%. The higher types of ARM had higher prevalence of OSD, except for vestibular fistula (20.5%). The prevalence of OSD in cloaca malformation, rectobladder neck fistula, rectoprostatic urethral fistula, rectobulbar urethral fistula, and perineal fistula were 28.6%, 33.3%, 16.7%, 12.5%, and 9.8%, respectively. Lumbosacral X-ray had a sensitivity of 51.7% and was not a good screening method. Sixteen of 65 U/S revealed OSD (24.6%). Tethered cord and syringomyelia were noted in nine and seven, respectively. Spinal MRI (n=39) revealed 27 OSD (69.2%) comprising 16 tethered cords, 12 spinal lipoma, and 10 syringomyelia. ARM associated with KUB anomalies had a statistically significant correlation with OSD. In 33 OSD, 17 patients (51.1%) were operated on. Fourteen received untethering spinal cord, while five had intradural lipoma excised. Conclusion: Patients with ARM had a high prevalence of OSD and should be screened for. U/S is the first-line method. MRI is strongly recommended in cloaca malformation, rectobladder neck fistula, rectoprostatic urethral fistula, vestibular fistula, and all ARM associated with KUB anomalies. Other types of ARM should be screened by MRI if feasible. Keywords: Spinal dysraphism, Tethered cord, Anorectal malformation

Minimal dissection of posterior wall of rectum reduces rectal prolapse in laparoscopic assisted anorectal pull-through

PurposeTo determine if minimal dissection of the posterior wall of rectum can reduce rectal prolapse after laparoscopic assisted anorectal pull-through (LAARP) in male anorectal malformation (ARM) with rectourethral fistula. MethodsEighty-six male patients with ARM who underwent LAARP in our center between 2007 and 2018 were retrospectively analyzed. There were 45 cases of prostatic urethral fistula, 24 bulbar urethral fistulas, and 15 bladder neck fistulas. Two patients had no fistula. To prevent rectal prolapses, we markedly shortened the length of posterior rectal dissection from mid-2016. Dissection of posterior wall of rectum was performed minimally around the level of the fistula and the dissected portion of the posterior rectum was significantly shorter than the previous cases. For comparative analysis, patients were divided into two groups (before and after application of minimal dissection of posterior wall of rectum): Group A, from 2007 to mid-2016 and Group B, from mid-2016 to 2018. ResultsThere were 60 patients in Group A and 26 patients in Group B. Demographic characteristics were not significantly different between the two groups. The median follow-up duration was 52.4 months for Group A and 26.9 months for Group B. Group B had lower incidence of rectal prolapse (11.5%) than Group A (68.3%) (p < 0.001). Upon our subgroup analysis based on types of fistula, patients with recto-prostatic urethral fistula and recto-bulbar urethral fistula showed significant reduction in the incidence of rectal prolapse (both p < 0.001). However, patients with recto-bladder neck fistula showed no statistical significance (p = 0.264). ConclusionMinimal dissection of the posterior wall of rectum can reduce rectal prolapse in LAARP. Level of evidenceIII. Retrospective Comparative Treatment Study

Transperineal Intracath Meconiolysis and Evacuation Technique of "Distended" Bowel Evacuation for One-Stage Laparoscopic Anorectoplasty for High Anorectal Malformations in Males.

Introduction: One-stage anorectoplasty provides maximum potential for "normal" defecation reflexes right at birth and avoids complications and problems of colostomy. One-stage laparoscopic anorectoplasty (OSLARP) for rectourinary fistula (RUF) is restricted by distended bowel obscuring the working space for laparoscopy. This study describes transperineal intracath meconiolysis and evacuation (TIME) technique for OSLARP in the treatment of RUF in neonates. Materials and Technique: High male anorectal malformation (ARM) admitted from January 2016 to March 2019 were included in the study. Diagnosis of level of ARM was made on the basis of invertogram. Patient presenting with lethal comorbidities were excluded who underwent colostomy. The technique involved placement of a 16G intracath in the perineum through the site of future neo-anus, which was identified using muscle stimulator. Meconiolysis and evacuation was done using warm saline and 2% N-acetyl. The creation of enough abdominal space was achieved after evacuation and two working instruments were placed in paraumbilical positions. The laparoscopic dissection and division of fistula was done as followed in standard laparoscopic anorectoplasty. Results: Seventeen patients were selected for TIME technique but on laparoscopy 2 patients had severe necrotizing enterocolitis hence they underwent laparoscopy-assisted high sigmoid colostomy. Fifteen patients underwent OSLARP successfully. Mean weight was 2.5 ± 0.4 kg, mean gestational age was 36 ± 5 weeks, and mean age of presentation was 3.5 ± 1 days after birth. The TIME technique was successful decompressing bowel in all the patients. Out of 15 patients of OSLARP, 14 had rectoprostatic urethral fistula and 1 had rectovesical fistula. Mean total operative duration of OSLARP was 46 ± 15 minutes. Patients who could be followed for 3 years had good results in terms of continence and bowel movements. Discussion: TIME technique is a very simple and effective way to overcome the problem of associated colonic distention in neonatal one-stage laparoscopic anoplasty.

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.

Institutional experience with laparoscopic-assisted anorectal pull-through in a series of 17 cases: A retrospective analysis.

Aims:To retrospectively analyse the results of laparoscopically-assisted anorectal pull-through (LAARP) for high anorectal malformation (ARM) in male children in our institution.Materials and Methods:We analysed the hospital records of patients who had undergone LAARP from October 2010 to December 2015 in terms of age, operative time, length of hospital stay and post-operative complications.Results:Of 17 cases, 13 (76%) were in 6–12 months age group, whereas rest of them were in 12–18 months age group. The recto-prostatic urethral fistula was encountered in 82% (n = 14) of patients and rectovesical type in two cases (12%). The mean operative time was 132 min with mean length of hospital stay being 4 days. Rectal mucosal prolapse was the most common complication noted.Conclusions:LAARP is a feasible approach to male children with high ARMs with less post-operative morbidity.

Nonfluoroscopic well-tempered pressure augmented distal colostogram in high-type anorectal malformation: Our experience

Background: Accurate imaging of rectourethral fistula is essential for optimal surgical management of infants with high-type anorectal malformation (ARM). The aim of this study was to study the role of nonfluoroscopic well-tempered pressure-augmented distal colostogram in high-type ARM in demonstrating rectourinary fistula, bladder anomalies, and for the presence of vesicoureteral reflux (VUR). Patients and Methods: We present a prospective study of 10 male infants who underwent a diverting colostomy in the neonatal period from January 2011 to December 2012. Our method of performing a colostogram is similar to conventional colostogram, but involves (a) meticulous bowel preparation preoperatively, ensuring that while doing the last distal colostomy wash before colostogram there is passage of clear saline from the urethral meatus to establish the presence of rectourinary fistula; (b) nonfluoroscopic study (c) performed with gentle and sustained pressure of contrast media, maintained over the period of the investigation; (d) bladder is completely filled with contrast media through rectourinary fistula and it is confirmed clinically; and (e) radiographic films in addition are taken in the micturating phase. Results: Rectourinary fistula was demonstrated in all (100%) cases. Rectoprostatic urethral fistula was present in three (30%) infants, rectobulbar urethral fistula in six (60%) patients, and one (10%) infant had type 4 congenital pouch colon (CPC) with colovesical fistula. Also three (30%) patients demonstrated unilateral primary vesicoureteral reflux (VUR), which was previously undiagnosed in all of them, as micturating cystourethrogram (MCU) was not attempted. Conclusions: Our study confirmed the level of anomaly and accurately demonstrated the type of fistula in all patients. It also detected the undiagnosed VUR in three (30%) cases. It obviated the need for a MCU.

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

Multicenter retrospective comparative study of laparoscopically assisted and conventional anorectoplasty for male infants with rectoprostatic urethral fistula

BackgroundLaparoscopically assisted anorectoplasty (LAARP) was expected to achieve better fecal continence than conventional procedures. However, the issue of which approach is better remains controversial. We compared outcomes between the conventional procedure and LAARP in male infants with rectoprostatic urethral fistula. MethodsInstitutes belonging to the Japanese Study Group of Anorectal Anomalies (JSGA) were invited to participate. Subjects were male infants with rectoprostatic urethral fistula treated by the conventional approach (abdominoperineal pull-through and PSARP) or LAARP between 2000 and 2006. Medical charts and operative records were reviewed retrospectively. ResultsEighty-one patients (conventional: 36, LAARP: 45) were enrolled from 15 centers. In both groups, the mean Kelly score was 5. The total score of the scoring system was newly developed by the Japanese Study Group of Anorectal Anomalies. Follow-up Project (5–15 points) was 10.7 and 12.1 in the conventional group and the LAARP group, respectively (p=0.07). The incidence of failed rectoanal anastomosis, mucosal prolapse, and anal stenosis was comparable in both groups. Posterior urethral diverticula were detected on cystourethrograms in 7% and 11% (p=1.0) and on MRI in 0% and 34% (p=0.02) of the conventional and the LAARP groups, respectively. Overall, 94% of diverticula were asymptomatic. ConclusionsFecal continence and complication rates after LAARP were comparable to those observed after the conventional method. Posterior urethral diverticula were detected more frequently after LAARP.

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.

Establishment of a rescue program for anorectal malformations induced by retinoic acid in mice

Aims of Study Retinoid-mediated signal transduction plays a crucial role in the embryogenesis of various organs. We previously reported the successful induction of anorectal malformations in mice using retinoic acid (RA). Retinoic acid controls the expression of essential target genes for cell differentiation, morphogenesis, and apoptosis through a complicated interaction in which RA receptors form heterodimers with retinoid X receptors. In the present study, we investigated whether the retinoid antagonist, LE135, could prevent the induction of anorectal malformations (ARMs) in mice. Methods Retinoic acid was intraperitoneally administered as 100 mg/kg of all-trans RA on E9; and then the retinoid antagonist, LE135, was intraperitoneally administered to pregnant ICR strain mice on the eighth gestational day (E8), 1 day before administration of RA (group B) or on E9, simultaneously (group C) with RA administration. All of the embryos were obtained from the uteri on E18. Frozen sections were evaluated for concentric layers around the endodermal epithelium by hematoxylin and eosin staining. Results In group A, all of the embryos demonstrated ARM with rectoprostatic urethral fistula, or rectocloacal fistula, and all of the embryos showed the absence of a tail. In group B, 36% of the embryos could be rescued from ARM. However, all of the rescued embryos had a short tail that was shorter than their hind limb. The ARM rescue rates in group B were significantly improved compared to those in group A ( P < .01). In group C, 45% of the embryos were rescued from ARM, but all of the rescued embryos had short tail. The ARM rescue rate in group C was significantly improved compared to that in group A ( P < .01). However, there was no significant difference in the ARM rescue rate between group B and Group C. Conclusion The present study provides evidence that in the hindgut region, RAR selective retinoid antagonist, LE135, could rescue embryos from ARM. However, the disturbance of all-trans RA acid was limited to the caudal region. Further study to establish an appropriate rescue program for ARM in a mouse model might suggest a step toward protection against human ARM in the future.

Neonatal posterior sagittal anorectoplasty for a subset of males with high anorectal malformations

Aim:To assess the results of primary posterior sagittal anorectoplasty (PSARP) in male neonates with high anorectal malformations (ARM) who on invertogram showed well descended rectum.Materials and Methods:Twelve full-term male neonates with high ARM over a period of one and half years were selected for primary PSARP based on the findings of invertogram. Primary PSARP was performed in all neonates with lower limit of rectal gas bubble at or below the ossified fifth sacral vertebra. The patients were followed-up for a period between three to four and half years. The clinical evaluation of fecal continence was performed using Pena's criteria for assessment of continence.Results:All neonates underwent PSARP on second to fourth postnatal day. The fistula with urinary tract was found in 11 patients (seven had fistula to bulbar urethra and four to prostatic urethra). Rectal tapering was not required in any neonate. No patient had urinary problems after removal of catheter. Most of the neonates were discharged by ninth day. Postoperatively, two patients had superficial wound infection of anoplasty without any disruption or bowel retraction. Two patients had severe perianal excoriation. No patient had anorectal stenosis. Nine of twelve patients on follow-up had good voluntary bowel movements. Of the three patients who had grade I soiling two had recto-prostatic urethral fistula. No patient had constipation. All patients had good urinary stream.Conclusions:Repair of high ARM in male neonates with a well descended rectum is feasible without significant morbidity and good continence.

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.

Residual fistula after laparoscopically assisted anorectoplasty: is it a rare problem?

Purpose Although various urologic complications have been reported after abdominoperineal pull-through and posterior sagittal anorectoplasty for the treatment of high-type imperforate anus, reports regarding complications after laparoscopically assisted anorectoplasty (LAARP) are surprisingly rare. Here, we discuss the potential complications of LAARP. Methods A retrospective study was conducted of 24 patients treated with LAARP from 2000 to 2006. The clinical and operative records were reviewed. Of the 24 patients, 18 were evaluated postoperatively by screening magnetic resonance imaging (MRI). Results The 24 participants are composed of patients with rectoprostatic urethral fistula (n = 15), rectal agenesis (n = 3), rectovesical fistula (n = 2), rectovaginal fistula (n = 2), and cloaca (n = 2). Defecatory function after LAARP was satisfactory. None of the patients had dysuria or urinary infection postoperatively. Cystic formations posterior to the urethra were demonstrated in 9 of the 18 cases examined by MRI. Postoperative voiding cystourethrography failed to demonstrate the lesion in 6 of 9 patients. The types of imperforate anus in this subgroup were rectoprostatic urethral fistula (n = 7), rectovesical fistula (n = 1), and rectal agenesis without fistula (n = 1). Average cyst diameter was 22 ± 19 mm. Two patients with large cysts (62 and 42 mm) underwent surgical resection. Conclusions Although satisfactory fecal continence could be achieved by LAARP, we experienced 2 cases with a large residual fistula that required surgical resection. In addition, screening MRI demonstrated the presence of cystic formations in 9 of 18 patients. We recommend that MRI be performed routinely during follow-up of patients treated with LAARP.