Sagittal Approach Research Articles

Dorsal onlay lingual mucosal graft urethroplasty: Comparison of two techniques

To compare the results of two different techniques of dorsal onlay lingual mucosal graft (LMG) urethroplasty for anterior urethral strictures. Thirty patients underwent dorsal onlay LMG urethroplasty by Barbagli's technique (group I) and 25 through a ventral sagittal urethrotomy approach (group II). All of the patients were followed up with a pericatheter urethrography at 3 weeks, retrograde urethrography with micturating cystourethrography and uroflowmetry at 3, 6 and 12 months. Mean follow up was 22 months and 13 months in group I and II, respectively. The mean peak flow rate increased from 4.2 mL/s preoperatively to 35.5, 25.06 and 25 mL/s at 3, 6, and 12 months, respectively, in group I and from 7.8 mL/s to 34.2, 28.4 and 26.2 mL/s at 3, 6 and 12 months, respectively, in group II. Five patients in group I and two patients in group II had an anastomotic stricture at 12 months. Meatal narrowing was seen in five patients in group I and three patients in group II. The overall success rate was 83.4% and 76.6% in group I and 90% and 80% in group II at 6 and 12 months, respectively. One patient had chordee in group I and no patient had chordee in group II. There was a shorter operative time and less blood loss in group II. Dorsal onlay LMG urethroplasty through a ventral sagittal approach is better than the Barbagli's technique in terms of results and complications.

One-stage Operation for Hirschsprung's Disease: Experience with 192 Cases

To report early and late outcomes after a one-stage operation for Hirschsprung's Disease (HD). Between December 2001 and December 2004, 192 patients (165 boys and 27 girls) underwent a one-stage operation for HD. Operative techniques included modified Pfannenstiel incision (48 cases), modified posterior sagittal approach (64 cases), and primary laparoscopic-assisted endorectal colonic pull-through procedure (80 cases). Ages ranged from 15 days to 36 months. The diagnosis was confirmed by operative frozen biopsies. An aganglionic segment was located in the rectum in 105 patients, in the sigmoid colon in 83 and in the left colon in four. There were no operative deaths. In one patient, a small intestinal perforation occurred 3 days after operation and required ileostomy. Anastomotic leakage occurred in four patients treated by modified posterior sagittal approach. The median hospital stay was 6 days, excluding five patients who required enterostomy. One hundred and forty-five patients were followed-up for 6-40 months after discharge from the hospital. All patients had spontaneous defaecation. The stool frequency ranged from one to four times daily in 113 patients, five to six times in 13, and over six times in four patients. There were seven patients with faecal incontinence and eight with constipation. One-stage operation is a safe procedure for HD.

Detubularized Pedicled Vaginal Onlay Flap Urethroplasty: A New Method for Hypospadias Repair of Ambiguous Genitalia

We introduce the detubularized pedicled vaginal onlay flap urethroplasty for single stage repair in ambiguous genitalia with perineoscrotal hypospadias and accompanying vagina, and report its preliminary surgical outcome. A total of 10 children with severe perineoscrotal hypospadias and genital ambiguity presenting with vagina and urogenital opening underwent single stage reconstruction with vaginal onlay urethroplasty. Through the posterior sagittal or abdominoperineal approach the vagina was released and pulled out, with care taken to preserve its vascular pedicle. Two incisions were made along the lateral margins of the vagina, reaching each other on the upper surface of the vaginal base, converting the vagina into a longitudinal flap twice as long as its original length. The vagina was then trimmed and reconfigured into a suitable sized flap to cover the urethral plate and form a neourethra with the onlay technique. The onlay-tube-onlay technique was also used in 2 patients with insufficient urethral plate. In 5 cases severe ventral chordee was also corrected concurrently with free vaginal graft to the ventral corpus cavernosum without further dorsal plication. The first 3 operations using the posterior sagittal approach failed due to improper surgical access, and the vagina was discarded. However, we achieved a satisfactory outcome with no failure after switching to an abdominoperineal approach. Immediate postoperative and short-term results revealed no urethrocutaneous fistula, urethral breakdown or necrosis at the distal end of the neourethra. Only 1 patient presented with severe mid shaft ring stricture, which required surgical revision. Incorporating the vagina of intersex patients into urethroplasty using detubularized pedicled vaginal onlay flap seems to provide a safe and practical method to treat severe hypospadias with genital ambiguity. Short-term satisfactory results are achievable by choosing the proper surgical approach and preserving the vaginal blood supply. However, longer followup in a large series of patients is needed before applying this method to clinical practice.

A modified approach for feminizing genitoplasty

We reported the use of the mucosal layer of preputial skin to give extra length to penile flaps on vaginal introitus and labia minora reconstruction in children with congenital adrenal hyperplasia. Since November 1999, 14 patients (average age 16 months, range 6 months-4 years) have undergone early one-stage reconstruction of external genitalia. All patients were classified according to Prader's classification (from III to V degree) with clitoral size of 3 +/- 1.5 cm. The perineal sagittal approach is followed by careful dissection and partial mobilisation of the urogenital sinus. Subcutaneous reduction clitoroplasty has been performed. The mucosal layer of the prepuce, developed as an extended flap on the end of the phallic shaft skin used for labia minora, is ideally placed for reconstruction of the vestibulae and distal vagina. The vagina was calibrated, the main vaginal calibre was 10 Hegar (range 6-14). With one exception, the urethral meatus was situated in the vestibulae and easily accessible. One distal vaginal stenosis was observed in a case with high confluence. No urinary incontinence was noted. The appearance of external genitalia was very satisfactory. The described genitoplasty provides a good cosmetic appearance. As most of our patients have not yet reached the age of sexual activity and child bearing, the functional results of this operation will need longer-term evaluation.

Dorsal Buccal Mucosal Graft Urethroplasty for Anterior Urethral Stricture by Asopa Technique

BackgroundBuccal mucosal graft (BMG) substitution urethroplasty has become popular in the management of intractable anterior urethral strictures with good results. Excellent long-term results have been reported by both dorsal and ventral onlay techniques. Asopa reported a successful technique for dorsal placement of BMG in long anterior urethral strictures through a ventral sagittal approach. ObjectiveTo evaluate prospectively the results and advantages of dorsal BMG urethroplasty for recurrent anterior urethral strictures by a ventral sagittal urethrotomy approach (Asopa technique). Design, setting, and participantsFrom December 2002 to December 2007, a total of 58 men underwent dorsal BMG urethroplasty by a ventral sagittal urethrotomy approach for recurrent urethral strictures. Forty-five of these patients with a follow-up period of 12–60 mo were prospectively evaluated, and the results were analysed. InterventionThe urethra was split twice at the site of the stricture both ventrally and dorsally without mobilising it from its bed, and the buccal mucosal graft was secured in the dorsal urethral defect. The urethra was then retubularised in one stage. Results and limitationsThe overall results were good (87%), with a mean follow-up period of 42 mo. Seven patients developed minor wound infection, and five patients developed fistulae. There were six recurrences (6:45, 13%) during the follow-up period of 12–60 mo. Two patients with a panurethral stricture and four with bulbar or penobulbar strictures developed recurrences and were managed by optical urethrotomy and self-dilatation. The medium-term results were as good as those reported with the dorsal urethrotomy approach.Long-term results from this and other series are awaited. More randomised trials and meta-analyses are needed to establish this technique as a procedure of choice in future. ConclusionsThe ventral sagittal urethrotomy approach is easier to perform than the dorsal urethrotomy approach, has good results, and is especially useful in long anterior urethral strictures.

Long-Term Efficacy of Distal Penile Circular Fasciocutaneous Flaps for Single Stage Reconstruction of Complex Anterior Urethral Stricture Disease

We determined the overall efficacy and predictors of success of the distal penile circular fasciocutaneous flap in the management of complex anterior urethral stricture disease not due to lichen sclerosus. We performed a retrospective review of all patients undergoing reconstruction of complex anterior urethral strictures without lichen sclerosus repaired from 1985 to 2006. Primary and overall stricture-free survival curves were estimated using the Kaplan-Meier method. Cox proportional hazards regression analysis was used to identify univariate and multivariate predictors of flap success. A total of 124 patients met the inclusion and exclusion criteria. Median patient age was 48 years (range 16 to 83). Median followup was 7.3 years (range 1 month to 19.5 years). Median stricture length was 8.2 cm (range 0.5 to 24). At 1, 3, 5 and 10 years the overall estimated stricture-free survival rates were 95%, 89%, 84% and 79%, respectively. On multivariate analysis smoking (HR 4.0, 95% CI 1.2-12.9, p = 0.02), history of hypospadias repair (HR 4.4, 95% CI 1.3-14.6, p = 0.01) and stricture length 7 to 10 cm (HR 7.0, 95% CI 1.4-34.7, p = 0.02) were predictive of failure. Fasciocutaneous flap urethroplasty has good and durable success rates in the treatment of complex anterior urethral strictures. Predictors of failure included smoking, history of hypospadias repair and longer stricture length.

Single-stage repair for rectovestibular fistula without opening the fourchette

Background Anorectal malformations are one of the most common congenital defects. This study is conducted to demonstrate new technique for treatment of rectovaginal fistula without disturbing the fourchette through posterior sagittal approach. Method All the patients of rectovestibular fistula admitted after the neonatal age were treated with posterior sagittal anorectoplasty without opening the fourchette. The results were evaluated for cosmetic appearance and anal continence. Result A total of 40 patients were included in our study. All patients were more than 1 month old. Operative time ranges from 70 to 150 minutes. The cosmetic appearance was good. Anal continence was good in 72% cases and fair in 20% cases. Fifteen percent of patients had minimal constipation and 7.5% patients had mucosal prolapse. Conclusion Single-stage repair for vestibular anus through posterior sagittal anorectoplasty without opening fourchette has a good cosmetic appearance and good anal continence.

Ultrasonographic procedure for a complete examination of the proximal third interosseous muscle (proximal suspensory ligament) in the equine forelimbs

SummaryUltrasonography of the proximal third interosseus muscle (PTIOM, suspensory ligament) is routinely performed for the diagnosis of the cause of proximal metacarpal/tarsal pain. As a result of the complex architecture and deep localisation of this ligament, performing and interpreting ultrasonographic images of this structure can be difficult.This paper describes an ultrasonographic procedure that allows complete imaging of the PTIOM in the forelimbs using a combination of approaches including sagittal and palmarocollateral approaches on the weightbearing limb with linear and convex probes. Moreover, the procedure includes images made on the flexed limb, thereby allowing a better contact and a more complete representation of the PTIOM and palmar aspect of the metacarpal bones.

Posterior sagittal approach in complicated Swenson′s pull-through

Context:Swenson's pull-through is one of the standard operations for the treatment of children with Hirschsprung's disease. Complications arising from the operation are difficult to treat because of fibrosis in the pelvis. The posterior sagittal approach may be a safer alternative.Aims:The aim of this paper is to highlight our experience with the use of the posterior sagittal trans-sphincteric approach to treat unusual complications of Swenson's pull-through.Settings and Design:A retrospective study of four patients who had posterior sagittal repair of their complications of Swenson pull-through at the Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria.Materials and Methods:Four cases of Hirschsprung's disease that developed post-Swenson pull-through complications are presented. There were three males and one female. Their age ranged between 10 months and 15 years. The patients had rectovaginal fistula, rectourethral fistula, high trans-sphincteric fistula-in-ano and complete anastomotic disruption.Result:All the patients were successfully treated using the posterior sagittal approach. The approach was used twice in one patient without significant sequelae. The three patients were old enough to be assessed and had a Kelly score of 4-6 at follow-up.Conclusion:The posterior sagittal technique offers a safe approach to treat the complications of Swenson pull-through.

Our Experience with Transanal Endorectal Pull-Through in Hirschsprung's Disease

The aim of the study was to evaluate the functional results, complications, the problems caused, and the outcomes of the transanal endorectal pull-through (TEPT) operation in Hirschsprung's disease. The 22 patients who were operated for Hirschsprung's disease with TEPT between November 2003 and September 2006 were reviewed retrospectively. The patients were evaluated for age, gender, operational findings, duration of hospitalization and functional outcomes after the operation. A total of 22 patients, sixteen males (72.7 %) and 6 females (27.3 %) aged 23 days to 11 years (mean 19.3 +/- 6.9 months), were operated using TEPT over a 34-month period. The mean length of the resected aganglionic segment was 23 +/- 2.4 cm; the shortest segment was 7 cm and the longest 40 cm. The postoperative hospital stay was 3 - 10 days, oral feeding was started at 1 - 4 days, the first bowel movement was at 1 - 7 days and the number of daily movements for patients in whom the colostomy was closed was 2 - 5. The mean postoperative follow-up period was 18 +/- 2.4 months (1 - 33 months). Two patients (9 %) were hospitalized once for enterocolitis. One patient had a constipation problem that resolved with medical treatment. One patient needed colostomy for anastomosis leakage on the 5th postoperative day, followed by a redo pull-through using a posterior sagittal approach. None of the patients had a continence problem. No urethral damage was observed and there were no abscesses at the muscular cuff. We observed that mucosal dissection was more difficult in the rectal biopsy area. Although only recently accepted, TEPT has quickly found a place in clinical practice as it is based on an operational technique whose results are well identified and accepted and with which there is extensive experience. It seems that TEPT has the advantages of having no additional problems compared to the classical techniques with respect to complications and functional outcomes while providing better patient comfort and cosmetic outcomes. We conclude that TEPT may be preferred in appropriate cases and will evolve to become a more practical and effective technique.

Anterior sagittal anorectoplasty for anovestibular fistula

Anterior sagittal anorectoplasty (ASARP) was used for the definitive correction in 107 cases of anovestibular fistula (AVF) between 1996 and 2005. These cases were subjected to three different types of treatment regimes during the same period. Majority of the cases (78) were operated in one stage where postoperatively an early oral feed was started (A). Cases were discharged in 2-4 days. In the second group (B), there were ten cases who were also operated in one stage but with prolonged fasting of 9-10 days postoperatively. Nineteen cases (C) were operated under cover of colostomy during the same period. In the immediate postoperative period, among the group A, one case had a major wound disruption requiring a colostomy and a redo surgery. Three cases had subcutaneous leak. In seven cases there was premature dehiscence of mucocutaneous or skin sutures. In groups B and C, there were no significant complications in the immediate postoperative period. In the follow-up period, out of 107 cases, 63 (58.8%) had constipation at the end of 3 months. However, at the end of one year, only 24.3% (26 cases) cases had constipation. Regarding fecal continence, 86 cases (90.5%) were totally continent. Seven had history of occasional soiling and in two cases, soiling was more frequent. As far as repair or correction of AVF or vestibular anus is concerned, we feel that anterior sagittal approach is more suitable as it requires less pelvic dissection. Separation of posterior vaginal wall from rectum, which is considered, is the most important step of the operation, takes place under direct vision. We also feel that AVF can be repaired in one stage with an early postoperative oral feed, provided we are meticulous in pre and postoperative bowel management. It reduces hospital stay and the cost of treatment. This provides a good option to cases who are not able to afford prolonged hospitalization (fasting) or are not willing for a colostomy.

Sphincter saving anorectoplasty (SSARP) for the reconstruction of Anorectal malformations

BackgroundThis report describes a new technique of sphincter saving anorectoplasty (SSARP) for the repair of anorectal malformations (ARM).MethodsTwenty six males with high ARM were treated with SSARP. Preoperative localization of the center of the muscle complex is facilitated using real time sonography and computed tomography. A soft guide wire is inserted under image control which serves as the route for final pull through of bowel. The operative technique consists of a subcoccygeal approach to dissect the blind rectal pouch. The separation of the rectum from the fistulous communication followed by pull through of the bowel is performed through the same incision. The skin or the levators in the midline posteriorly are not divided. Postoperative anorectal function as assessed by clinical Wingspread scoring was judged as excellent, good, fair and poor. Older patients were examined for sensations of touch, pain, heat and cold in the circumanal skin and the perineum. Electromyography (EMG) was done to assess preoperative and postoperative integrity of external anal sphincter (EAS).ResultsThe patients were separated in 2 groups. The first group, Group I (n = 10), were newborns in whom SSARP was performed as a primary procedure. The second group, Group II (n = 16), were children who underwent an initial colostomy followed by delayed SSARP. There were no operative complications. The follow up ranged from 4 months to 18 months. Group I patients have symmetric anal contraction to stimulation and strong squeeze on digital rectal examination with an average number of bowel movements per day was 3–5. In group II the rate of excellent and good scores was 81% (13/16). All patients have an appropriate size anus and regular bowel actions. There has been no rectal prolapse, or anal stricture. EAS activity and perineal proprioception were preserved postoperatively. Follow up computed tomogram showed central placement the pull through bowel in between the muscle complex.ConclusionThe technique of SSARP allows safe and anatomical reconstruction in a significant proportion of patients with ARM's without the need to divide the levator plate and muscle complex. It preserves all the components contributing to superior faecal continence, and avoids the potential complications associated with the open posterior sagittal approach.

POS-01.43: Dorsal free buccal mucosal graft urethroplasty for recurrent anterior urethral strictures via ventral sagittal urethrotomy approach

AIM: To evaluate the results and complications of single stage dorsal free buccal mucosal graft urethroplasty using ventral sagittal urethrotomy approach.

Laparoscopic assisted endorectal pull-through with posterior sagittal approach to the repair of postoperative rectourethral and rectovaginal fistula

Rectourethral or rectovaginal fistula is a troublesome complication after anorectal surgery. The pelvic and perineal dissection may be difficult because of severe fibrosis adhesion around the fistula. The authors applied a novel technique: a combined laparoscopic assisted abdominal and posterior sagittal approach (PSA) to perform the redo surgery. Three boys and two girls (3-13 years old): case 1 had rectovaginal fistula after rectal dialation and modified Swenson's procedure; case 2 had rectovestibular fistula after twice perineal anorectoplasty; case 3 had rectourethral fistula after twice anorectoplasty; case 4 was imperforate anus with Hirschsprung's disease and rectourethral fistula that had been misdiagnosed; case 5 had rectourethral fistula after abdominoperineoanoplasty and Mollard procedure and posterior sagittal anorectoplasty. Laparoscopic assisted abdominal dissection was done first to mobilize the colon as far as the mid pelvis, and the normal colon was marked with a suture. The lower pelvic dissection was performed through the posterior sagittal route, the proximal rectum was mobilized and servered, the distal rectum was left undisected, endorectal mucosectomy with electric ablation was performed, then the fistula was closed from inside the rectum, and the stump of the colon was pulled through the rectum, the stump and the dentate line were anastomosed extraanally. Colostomy was done in case 2 and case 5. The postoperative follow-up showed no recurrent fistula, and all patients had attained normal voluntary bowel actions, but one child had infrequent minor soiling. Laparoscopic assisted endorectal pull-through of the intact colon can offer precise dissection, minimal abdominal injure, and spare troublesome mobilization of the fistula, and can prevent the recurrent of fistula. Posterior sagittal approach provides a direct repair of the fistula and anastomosis.

The Posterior Sagittal Approach for Recurrent Genitourinary Pathology

The posterior sagittal transanorectal approach offers the surgeon excellent exposure to the lower genitourinary system. The approach has been successfully used for revisional surgery involving the urinary tract and rectum. We have used this approach to treat müllerian remnants, acquired or congenital fistulas and acquired urethral strictures. In the setting of revisional surgery abdominal or perineal approaches may not provide the same level of exposure to the lower urinary tract. Of 911 males who underwent a posterior sagittal approach 12 were identified in whom this approach was used to manage lower urinary tract problems without associated anorectal malformation (group 1). An additional 58 patients with associated anorectal malformations were included in analysis (group 2). All cases were approached with a posterior sagittal incision to facilitate exposure after failed prior surgical attempts to treat traumatic strictures of the proximal urethra in 4 and müllerian remnants in 8 (group 1). In group 2 there were 19 urethral diverticula, 8 strictures and 31 persistent rectourethral fistulas. Followup was 6 months to 15 years. There were no recurrences identified in group 1. In group 2 there were 5 postoperative urethrocutaneous fistulas. Data on potency were available on 4 patients in group 1 and 14 in group 2. All 14 patients in group 2 reported intact potency after surgery. One patient in group 1 was impotent before and after surgery. The posterior sagittal approach is helpful for addressing lower urinary tract pathology when exposure is inadequate from a perineal or abdominal approach. We propose that better exposure with this approach may limit inadvertent injury to nerves and result in more complete treatment of the presenting pathological condition. This approach provides an alternative that warrants careful consideration when dealing with the lower genitourinary tract in pediatric patients, especially in the setting of revisional surgery.

Modified Posterior Sagittal Transanorectal Approach in Repair of Urogenital Sinus Anomalies

To describe the operative details and results of a modified posterior sagittal transanorectal approach for the reconstruction of urogenital sinus (UGS) anomalies. Six children with UGS anomalies underwent surgery using this technique. In a prone jack-knife position, a midline incision was continued to the puborectalis muscle. A plane of dissection was created circumferentially around the rectum separating it from the underlying UGS. Circumferential transanal mucosectomy and a transanal dissection was carried proximally for 5 to 10 cm. The mucosal tube with the serosal wall was resected, exposing the proximal part of the UGS. The posterior and anterior sphincters, anus, and perineal body were then divided in the midline, completely exposing the UGS. Reconstruction of the urethra and vagina was done. At completion of UGS reconstruction, an endoanal pull through of the rectal tube and a low coloanal anastomosis were performed. The muscle complex and perineal body were closed in layers. The modified technique of posterior sagittal transanorectal approach allowed excellent exposure in all 6 patients. None developed any complications related to suture line leak. Fecal and urinary continence was preserved in patients who were continent before the operation. The modified posterior sagittal transanorectal approach is a safe and effective technique in the treatment of UGS anomalies and can be performed without the need for a protective colostomy.

Anorectal malformations

Anorectal malformations comprise a wide spectrum of diseases, which can affect boys and girls, and involve the distal anus and rectum as well as the urinary and genital tracts. They occur in approximately 1 in 5000 live births. Defects range from the very minor and easily treated with an excellent functional prognosis, to those that are complex, difficult to manage, are often associated with other anomalies, and have a poor functional prognosis. The surgical approach to repairing these defects changed dramatically in 1980 with the introduction of the posterior sagittal approach, which allowed surgeons to view the anatomy of these defects clearly, to repair them under direct vision, and to learn about the complex anatomic arrangement of the junction of rectum and genitourinary tract. Better imaging techniques, and a better knowledge of the anatomy and physiology of the pelvic structures at birth have refined diagnosis and initial management, and the analysis of large series of patients allows better prediction of associated anomalies and functional prognosis. The main concerns for the surgeon in correcting these anomalies are bowel control, urinary control, and sexual function. With early diagnosis, management of associated anomalies and efficient meticulous surgical repair, patients have the best chance for a good functional outcome. Fecal and urinary incontinence can occur even with an excellent anatomic repair, due mainly to associated problems such as a poorly developed sacrum, deficient nerve supply, and spinal cord anomalies. For these patients, an effective bowel management program, including enema and dietary restrictions has been devised to improve their quality of life.

The fetal corpus callosum. ‘The truth is out there’

The fetal corpus callosum. ‘The truth is out there’

A Posterior Sagittal Pararectal Approach for Repair of Posterior Urethral Distraction Injuries

ObjectiveTo report our initial experience with the posterior sagittal pararectal approach as an alternative in the treatment of complicated urethral distraction defect after pelvic trauma. Patients and methodsTwenty-four patients with posttraumatic pelvic fracture urethral distraction defects (PFUDDs) underwent urethroplasty in our department from March 2003 to June 2006. In 7 of those patients, the posterior sagittal pararectal approach was utilised. Of the 7 patients, 5 had failed previous transperineal repair, whereas the other 2 had long-distance urethral distraction defect. Follow-up included retrograde urethrography (RUG) and uroflowmetry, which were done postoperatively at 3 wk and 3, 12, and 18 mo, and thereafter when needed. Clinical outcome was considered a success at the time that no postoperative procedure was needed. ResultsOf the 7 patients, 5 were in the paediatric group with ages ranging from 9 to 14 yr, whereas 2 patients were adults (21 and 50 yr). The aetiology of PFUDDs in all patients was road traffic accident. Median length of the stricture was 5cm. The median operative time was 240min, whereas the median hospital stay was 10 d. Postoperatively, 1 patient developed gluteal abscess that was successfully managed conservatively. Follow-up period ranged from 7 to 32 mo (median: 13 mo). All patients showed criteria of success including satisfactory uroflowmetry (median Qmax: 18ml/s), patent RUG, and subjective improvement in the voiding pattern. Only 1 patient developed difficulty 1 mo postoperatively and was successfully managed by urethral dilation. ConclusionsThis technique is a good alternative approach for repair of complicated PFUDDs. It is safe and has the advantage of better visualisation of the apex of the prostate and surgical field, with subsequent good outcomes without immediate or remote effects on the sphincteric function of the rectum or bladder. Further studies with larger cohort of patients are needed to justify the specific indications of this approach.

The Surgical Outcome of Total Urogenital Mobilization for Cloacal Repair

Total urogenital mobilization is deemed to preserve the urogenital sinus blood supply and avoid ischemic complications. We report our experience with this technique for cloacal repair. We retrospectively reviewed all consecutive cases of persistent cloaca managed by total urogenital mobilization via a posterior sagittal approach by a single pediatric urologist between 1998 and 2003. During this period 22 girls (12 with a common channel longer than 3 cm) underwent total urogenital mobilization for cloaca repair (1 redo) at a median age of 10 months (range 2 to 102). A total of 15 procedures (68%) could be completed by a perineal approach only. Four patients with a long common channel required additional maneuvers after mobilization to complete the reconstruction. Urethral stenosis was observed in 2 patients after urethral separation from the vagina (1) and common channel retubularization (1). One child with a perineal hemangioma required a redo posterior sagittal anorectoplasty for complete vaginal and anal closure. In addition, 1 case of urethrovaginal fistula was diagnosed on cystovaginoscopy but was asymptomatic, and 1 child with a minor residual common channel underwent urethral revision to allow easier intermittent catheterization. With a median followup of 48 months (range 11 to 162) the latest examination involving endoscopy with anesthesia showed a good result in 17 patients, a tight introitus that might require further surgery in 3 and a minimal residual common channel of 0.5 cm in 2. Total urogenital mobilization is an effective technique for repairing short and long common channels, and a low surgical complication rate can be anticipated.