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

Abstract

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.

Intraoperative measurement of rectourethral fistula: prevention of incomplete excision in male patients with high-/intermediate-type imperforate anus

“…During dissection of the RUF in male patients with high-/ intermediate-type imperforate anus, there is potential risk for posterior urethral diverticulum to develop because complete excision of any RUF is not easy, even if it is prostatic; if it is bulbar, it is even more difficult, as previously described [7], because the rectum and the prostate/urethra at the fistula share a common wall. Most pediatric surgeons would concede that it is better to risk the potential of a small diverticulum developing because of incomplete excision rather than to cause urethral injury/stenosis by dividing the fistula too close to the urethra [9,10].…”

“…By using a fine flexible endoscope introduced through an opening made in the anterior rectal wall, laparoscopic dissection could also be monitored intraluminally, assisting the laparoscopic surgeon to dissect the RUF closer towards its distal end [7]. Another reported procedure involves subseromuscular dissection of the rectum up to where the fistula joins with the urinary tract during LAARP [5].…”

“…Laparoscopically assisted anorectal pull-through was performed according to a technique described previously elsewhere [1,[6][7][8]. Briefly, the RUF was dissected close to the urethra, taking great care to avoid injuring the vas and prostate, and then opened.…”

Cystoscopic-assisted excision of rectourethral fistulas in males with anorectal malformations

“…No matter how skilled, a surgeon will perform better with accurate intraoperative marks. In the laparoscopic-assisted anorectal pull-through (LAARP) procedure [8], Atsuyuki [6] initially used endoscopy to label the rectourethral fistula. By inserting a flexible endoscope into the rectum through an opening made in the anterior rectal wall, both the urethral and rectal orifices of the fistula as well as the level of the laparoscopic dissection could be observed intraluminally.…”

“…Many methods have been used to identify rectourethral fistulas, including preoperative augmented pressure colostogram [3] and intraoperative endoscopy [4][5][6]. In this study, we performed cystoscopy and labeled the rectourethral fistula with a ureteral catheter before posterior sagittal anorectoplasty (PSARP).…”