Single-Stage Surgical Correction of Anorectal Malformation Associated With Rectourinary Fistula in Male Neonates
Single-Stage Surgical Correction of Anorectal Malformation Associated With Rectourinary Fistula in Male Neonates
ORIGINAL ARTICLE
Single-Stage Surgical Correction of Anorectal Malformation Associated
with Rectourinary Fistula in Male Neonates
Ernesto Leva1, Francesco Macchini1,* Rossella Arnoldi1, Antonio Di Cesare1, Valerio Gentilino1,
Monica Fumagalli2, Fabio Mosca2, Akbar Bhuiyan3, Maurizio Torricelli1, Tahmina Banu3
1
Dept. of Pediatric Surgery, FONDAZIONE IRCCS CA GRANDA Ospedale Maggiore Policlinico, Milan Italy
Neonatal ICU, FONDAZIONE IRCCS CA GRANDA Ospedale Maggiore Policlinico, Milan Italy
ABSTRACT
Introduction: The treatment of children affected by ano-rectal malformations (ARM) is characterized by some unsolved problems. The three-stage surgical correction has been known
to be most effective in preventing complications, but recently new approaches have been
proposed. We describe our experience with the newer approaches.
Methods: Twenty three male newborns, affected by ARM and recto-urinary fistula, were
treated in 2 different centers in 8 years. Nineteen neonates (birth weight 2.4 - 3.5 kg) received a primary posterior sagittal anorectoplasty (PSARP) at the Department of Pediatric
Surgery of the Chittagong Medical College Hospital (group 1). Four term neonates (birth
weight 2.9 - 3.4 kg) received a primary pull-through with combined abdomino-perineal approach at the Pediatric Surgery Department of Fondazione C Granda of Milan (group 2).
Results: Among patients of Group 1, 11 patients had a recto-bulbar fistula and 8 a rectoprostatic fistula. Among the Group 2, 2 had a recto-bulbar fistula and 2 a recto-prostatic fistula. The site of fistula was decided at the time of surgery. In Group 1, 5 post-surgical complications were recorded (26%); 1 child died of sepsis, 3 had dehiscence and 1 stenosis,
which resolved with dilatation. In Group 2, the only post-operative complication of small
rectal prolapse resolved spontaneously after a few months on follow-up. Group 2 patients
were followed-up in a dedicated multidisciplinary colorectal center.
Conclusions: Primary repair of ARMs with recto-urinary fistula is a feasible, safe and effective technique in the neonatal period. A combined abdominal and perineal approach seems
to guarantee better results. A dedicated team is mandatory, both for the surgical correction
and for a long-term follow-up.
Key words: Anorectal malformation, Primary repair, Recto-urinary fistula
INTRODUCTION
The management of children affected by anorectal malformations (ARM) is still affected by
some unsolved problems. Pena advocates 3
staged management- colostomy at birth, posterior sagittal ano-recto-plasty (PSARP) and closure of colostomy for males neonates affected
*
Corresponding Author
by ARM associated with recto-urinary fistula [13]. This surgical approach is considered the
most effective in preventing incontinence,
thanks to its meticulous respect of the perineal
structures [4]. In the last 2 decades, with the
advent of laparoscopy, new approaches to
ARMs were proposed, at first by Willital and
then by Georgeson [5]. The laparoscopy was
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Single-Stage Surgical Correction of Anorectal Malformation Associated with Rectourinary Fistula in Male
Neonates
very useful in identifying the rectal wall, isolating and closing the fistula, thus facilitating
the anorectoplasty. The results of two different
techniques of primary repair performed in two
Departments of Pediatric Surgery are here analysed: in the first group a posterior sagittal approach was chosen, while in the second one a
combined abdominal and perineal correction
was preferred.
MATERIALS AND METHODS
From January 2002 to December 2009, 23
male newborns affected with ARM associated
with recto-urinary fistula were treated in 2 different centers within first 48 hours of lives.
The diagnosis of ARM with recto-urinary fistula
was easily established within first 24 hours of
birth. An invertogram was obtained 24 hours
after birth in all the patients to determine the
distance between the rectal pouch and the proposed anal site. Neonates without evidence of
meconium in urine after 24 hours from birth
and neonates with a delayed presentation after
48 hours from birth were excluded by the
study. No other exclusion criteria, such as associated cardiac diseases, were considered.
Group 1 consisted of 19 neonates (gestational
age 35 - 41 weeks; birth weight 2.4 - 3.5 kg)
who underwent a primary PSARP at the Department of Pediatric Surgery of the Chittagong
Medical College Hospital. Among them, 37%
were born by caesarean section. Four patients
had cardiac malformations (atrioseptal defect
(n=2); ventriculoseptal defect (n=1); pulmonary
stenosis (n=1)), while 9 had genito-urinary malformations (vesicoureteral reflux (n=4); hypospadias (n=3); multicystic kidney (n=1) and 1
ectopic kidney (n=1).
Group 2 consisted of 4 term neonates (birth
weight 2.9 - 3.4 kg) who received a primary
pull-through with combined abdomino-perineal
approach at the Pediatric Surgery Department
of Fondazione C Granda of Milan, Italy. All of
them had a spontaneous delivery and a regular
post-natal course. There were no associated
cardiac and renal malformations in this subgroup. The study of lumbo-sacral anomalies
Single-Stage Surgical Correction of Anorectal Malformation Associated with Rectourinary Fistula in Male
Neonates
Single-Stage Surgical Correction of Anorectal Malformation Associated with Rectourinary Fistula in Male
Neonates
The satisfactory results, in terms of post-surgical complications, were obtained taking extreme care to respect some fundamental principles: to dissect the perineum close to the rectum in order to avoid injuries to the pelvic autonomic nerve of bladder and penis; to isolate
carefully the recto-urinary fistula, taking attention not to damage the urethra; to dilate
progressively the perineum to avoid strictures;
to perform the anoplasty with the same principles of PSARP, included the use of the Pena
stimulator to determine the anal site [7].
Primary repair of ARMs with recto-urinary fistula is a feasible, safe and effective technique in
the neonatal period. A combined abdominal
and perineal approach seems to guarantee better results. Further studies are needed to evaluate if the incidence of surgical and functional
complications is similar to the traditional
staged management. The role of a dedicated
team is mandatory, both for the surgical correction and for a long-term follow-up.
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Single-Stage Surgical Correction of Anorectal Malformation Associated with Rectourinary Fistula in Male
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How to cite:
Leva E, Macchini F, Arnoldi R, Di Cesare A, Gentilino V, Fumagalli M, et al. Single-stage surgical correction of anorectal
malformation associated with rectourinary fistula in male neonates. J Neonat Surg. 2013; 2: 3.