Accuracy of pre-operative fistula diagnostics in anorectal malformations

Abstract

Background Surgical safety during posterior sagittal anorectal plasty (PSARP) for anorectal malformations (ARM) depends on accurate pre-operative fistula localization. This study aimed to evaluate accuracy of pre-operative fistula diagnostics. Methods Ethical approval was obtained. Diagnostic accuracy of pre-PSARP symptoms (stool in urine, urine in passive ostomy, urinary tract infection) and examination modalities (voiding cystourethrogram (VCUG), high-pressure colostogram, cystoscopy and ostomy endoscopy) were compared to final intra-operative ARM-type classification in all male neonates born with ARM without a perineal fistula treated at a tertiary pediatric surgery center during 2001–2020. Results The 38 included neonates underwent reconstruction surgery through PSARP with diverted ostomy. Thirty-one (82%) had a recto-urinary tract fistula and seven (18%) no fistula. Ostomy endoscopy yielded the highest diagnostic accuracy for fistula presence (22 correctly classified/24 examined cases; 92%), and pre-operative symptoms the lowest (21/38; 55%). For pre-operative fistula level determination, cystoscopy yielded the highest diagnostic accuracy (14/20; 70%), followed by colostogram (23/35; 66%), and VCUG (21/36; 58%). No modality proved to be statistically superior to any other. Conclusions Ostomy endoscopy has the highest diagnostic accuracy for fistula presence, and cystoscopy and high-pressure colostogram for fistula level determination. Correct pre-operative ARM-typing reached a maximum of 60–70%.

Can Neonatal Pull-Through Replace Staged Pull-Through for the Management of Anorectal malformation? a Systematic Review and Meta-Analysis

“…[ 29 ] The accurate delineation of pathological anatomy increases safety by minimizing avoidable surgical trauma or injuries to the urinary and genital tract. [ 31 ] Urinary tract injury may be predisposed to either by improperly performed distal colostogram providing incomplete information or to variation in the technique that the surgeons employ for pull-through. [ 18 ]…”

“…[ 14 ] Cross table prone lateral X-ray, cystoscopy, voiding cystourethrography, and magnetic resonance imaging can also provide reliable knowledge about the level of the distal rectal pouch. [ 14 17 29 31 32 33 34 35 ] The stoma allows the pediatric surgeon to perform pressure augmented distal colostogram for better delineation of the anomaly. [ 17 ] albeit an operator-dependent investigation and carries a risk of radiation exposure and a bowel perforation.…”

“…[ 17 ] albeit an operator-dependent investigation and carries a risk of radiation exposure and a bowel perforation. [ 31 32 ] Some authors believe as the approach during LAARP is from the pelvic side, the knowledge of the exact level of the fistula may be not required by preoperative radiological investigations, as the diagnosis can be safely made intra-operatively under direct vision. [ 27 36 37 ]…”

3D Fluoroscopic imaging facilitates reconstruction of common urogenital sinus and cloacal anomalies

“…19 (Figure 2A) Prior studies have reported an accuracy of 66% for colostogram and 58% for VCUG for identifying the level of the fistula. 20…”

Preoperative fistula diagnostics in male anorectal malformations after colostomy: a single-center experience

“…High-pressure colostogram (HPC) is considered the most effective method for diagnosing fistulas, but there is a lack of large-scale comparative study and the previous studies have some methodological issues [ 10 ]. Voiding cystourethrogram (VCUG) is helpful in the diagnosis of fistula [ 7 ], but there is controversy concerning when it should be performed [ 8 ]. Performing HPC and VCUG on all patients increases the dose of radiation and is unnecessary.…”