Keywords
anorectal malformation - posterior sagittal anorectoplasty - newborns - endoscopy
- rectourethral fistula
Introduction
When reconstructing an anorectal malformation (ARM) with posterior sagittal anorectoplasty
(PSARP), the dissection of the rectourethral fistula is one of the challenges. The
PSARP procedure includes opening the rectum posteriorly to clarify the anatomy before
dividing the rectourethral fistula.[1] The aim of this report is to describe an approach including placing of a guidewire
passed through the endoscope in the colostomy, through the fistula to the urethra
to facilitate the localization and dissection of the rectourethral fistula early in
the operative intervention.
Case Report
A boy was born in the 38th gestational week, with a birth weight of 2,980 g. On examination,
he was found to have an anal atresia without fistula to the perineum. No other congenital
malformations were discovered.
At the age of 20 hours postpartum, the boy was provided with a left loop divided colostomy
by a laparoscopic approach. At the age of 6 weeks, the boy was scheduled for a PSARP
operation. Preoperative colon X-ray examination disclosed the open rectourethral fistula
in the distal end of the rectum.
Before the PSARP operation, an endoscope was inserted through the distal stoma and
the fistula to the urethra was identified at the distal end of the rectum. A guidewire
was passed through the endoscope into the fistula and out through the urethra ([Figs. 1] and [2]). A catheter was placed into the urinary bladder in the traditional way through
the urethra. Video endoscope of 6.5 mm, a guidewire of 2.5 mm, and bladder catheter
of 6 Charrière were used.
Fig. 1 Through the videoendoscope the rectourethral fistula is easily identified and a guidewire
is passed through the videoendoscope and through the rectourethral fistula.
Fig. 2 Through the endoscope of 9 mm, a guidewire of 2.5 mm has been passed through the
rectourethral fistula.
The PSARP operation was performed. The dissection of the rectourethral fistula was
facilitated by the guidewire in the fistula. The fistula could initially be shown
and dissected without opening the rectum and the guidewire was visualized on opening
the distal end of the rectum. Surgical damage to surrounding tissues and intestine
was thereby avoided by using this artificial benchmark of the fistula. No dissection
in search of the rectourethral fistula was needed. During the PSARP operation, the
fistula was divided and used for reconstructing the new anus, while the opening to
the urinary tract was left without suture.[2]
The postoperative course was uneventful. An X-ray of the urinary bladder and urethra,
voiding cystourethrogram, performed 6 weeks later showed a normal urinary tract without
any fistula to the bowel.
Discussion
This case report demonstrates the use of an endoscopy-aided placement of a rectourethral
guidewire to facilitate the reconstruction of anus in patients born with ARM. Reliable
placement of a catheter in the fistula through the urethra is impossible. The placement
of a guidewire from the distal end of the rectum to the urethra was found to be easy.
A guidewire through the fistula facilitates the dissection and thereby helps avoiding
any unnecessary dissection searching for the rectourethral fistula. The anatomy becomes
clearer, and with the wire in place, opening of the intestine during the initial part
of the dissection is prevented. By using the guidewire, the leveling of the division
or the fistula is facilitated. Any suspicion of nonexisting fistula could be disregarded
through the view from the endoscope.
With the video endoscope introduced through the distal stoma, it is usually easy to
identify the rectourethral fistula preoperatively. The risk of damage to the urethra
may be reduced and that might lead to fewer problems with urethral stricture or urethral
diverticula. With more exact dissection, it is easier to save the tissues in the fistula
for reconstruction of the anus. Furthermore, the air in the bowel introduced through
the endoscope facilitates the dissection of the blind-ending bowel.
Endoscopy-assisted laparoscopic excision of rectourethral fistula in a male patient
with imperforate anus has been described without the use of any guidewire.[3] By using the method described here, laparoscopy/laparotomy intervention in the abdomen
is facilitated.
To summarize, we have found that the method described here has facilitated the PSARP
intervention. Since the first time this operative intervention described here was
performed, we have used the method in several children with ARM with rectourethral
fistula, including a child with cloaca. When performing these interventions, we suggest
that both options for placing a guidewire through a cystoscopy from the urethra or
from a video endoscope from the bowel should be available. We hereby submit the method
for evaluation by others.
