Journal of Pediatric Surgery xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Operative Techniques
Cystoscopic-assisted excision of rectourethral fistulas in males with anorectal malformations Yichen Huang a, Weijue Xu b, Hua Xie a,⁎, Yibo Wu b, Zhibao Lv b, Fang Chen a a b
Department of Urology, Shanghai Children’s Hospital, Shanghai Jiaotong University, Shanghai, China Department of General Surgery, Shanghai Children’s Hospital, Shanghai Jiaotong University, Shanghai, China
a r t i c l e
i n f o
Article history: Received 12 August 2014 Received in revised form 15 March 2015 Accepted 6 April 2015 Available online xxxx Key words: Cystoscopy Rectourethral Fistula Anorectal Malformation
a b s t r a c t Introduction: We report a novel technique to label rectourethral fistulas in males with anorectal malformations who are undergoing posterior sagittal anorectoplasty (PSARP) to facilitate complete excision of the fistula. Methods: Prior to performing PSARP in 21 male patients with rectourethral fistulas, cystoscopy was carried out to identify the orifice of the fistula within the urethra. A 3Fr ureteral catheter with calibrations was then inserted into the orifice to label the fistula. During the PSARP procedure, the rectourethral fistula was dissected to the junction of the urethra, as identified by the presence of the ureteral catheter, and the fistula tract was completely excised. Results: Six prostatic and 15 bulbar rectourethral fistulas were found by cystoscopy. The orifices of the rectourethral fistulas were all located in the midline along the dorsal wall of the posterior urethra. The average length of the rectourethral fistulas was 10 mm (range = 5–15 mm). During the PSARP procedure, the rectourethral fistula could be clearly identified, easily dissected and completely excised. Patients were followed up for 7–24 months. During the length of follow-up, micturition was normal and no urethral complications were found in any of the 21 patients. Conclusion: Intraoperative cystoscopy with placement of a ureteral catheter in the fistula tract facilitates complete excision of rectourethral fistulas in males with anorectal malformations without risking injury to the urethra. © 2015 Elsevier Inc. All rights reserved.
More than 80% of boys born with anorectal malformations (ARM) have a rectourethral fistula [1]. Although significant advances have been achieved in surgical interventions, many children still experience urethral complications which are potentially avoidable. The most commonly reported complications are recurrent rectourethral fistulas (23.3%), urethral injuries (20.2%) and posterior urethral diverticula (17.8%) [2]. Accurate identification of a rectourethral fistula and its relationship with the urethra is important to enable complete excision of the rectourethral fistula and prevent urethral complications. Many methods have been used to identify rectourethral fistulas, including preoperative augmented pressure colostogram [3] and intraoperative endoscopy [4–6]. In this study, we performed cystoscopy and labeled the rectourethral fistula with a ureteral catheter before posterior sagittal anorectoplasty (PSARP). This procedure allows surgeons to easily mark the fistula and thereby facilitates complete excision of the rectourethral fistula without injuring the urethra.
⁎ Corresponding author at: Department of Urology, Shanghai Children’s Hospital, Shanghai Jiaotong University. No 355, Luding Rd, Shanghai, 200062, China. Tel.: +86 18917128147; fax: +86 021 62790494. E-mail address: [email protected] (H. Xie).
1. Methods This study was performed in 21 male patients with ARM and rectourethral fistula who underwent PSARP at our institution from 2011 to 2013. The rectourethral fistula was either diagnosed by preoperative augmented pressure colostogram (19/21) or suspected based upon the presence of stool in the patient’s urine (2/21). The mean age of patients was 7.6 months (range = 6–9 months). All surgeries were performed by the same group of surgeons. An initial descending colostomy was performed in 20/21 patients shortly after birth at our institution. One patient underwent a loop transverse colostomy at another hospital before being transferred to our institution. Before surgery, an augmented pressure colostogram was conducted to confirm the level of rectal atresia and any associated fistulous communication [3] (Fig. 1). The patient was then placed in lithotomy position. Cystoscopy was performed by a urologist. The prostatic urethra, bulbar urethra and bladder neck were carefully examined. A 3Fr ureteral catheter was used to probe any suspected orifice. When a rectourethral fistula did exist, the catheter could be inserted with ease (Fig. 2). In one case, although the initial colostogram indicated the presence of a rectourethral fistula, only the tip of the catheter could be inserted into the suspected orifice. Instead, we injected undiluted methylene blue through the catheter to stain the fistula tract. After cystoscopy, a 6Fr Foley catheter was placed per urethra into the bladder.
http://dx.doi.org/10.1016/j.jpedsurg.2015.04.002 0022-3468/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Huang Y, et al, Cystoscopic-assisted excision of rectourethral fistulas in males with anorectal malformations, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.04.002
2
Y. Huang et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
10 mm (5–15 mm). Notably, preoperative colostogram had identified the presence of a rectourethral fistula in 19/21 patients, and the locations of each fistula were consistent with the results obtained from cystoscopy. All Foley catheters were removed 7 days postoperatively. Patients were followed for 7–24 months postoperatively. In all 21 patients, micturition was normal and no urethral complications were found on follow-up.
3. Discussion
Fig. 1. Preoperative augmented pressure colostogram shows the level of rectal atresia and the rectourethral fistula. R, rectum; Bl, bladder; asterisk, junction of urethra and fistula.
The patient was then changed to prone position, and a standard PSARP procedure was performed [7]. Once the rectum was opened longitudinally along the midline, the catheter labeling the fistula could be observed clearly (Fig. 3). In the single case in which methylene blue was used, the rectourethral fistula tract was visibly stained. The rectourethral fistula was further dissected to the junction of the urethra with help of the catheter. The length of the rectourethral fistula was then measured. Finally, the rectourethral fistula was completely excised and closed with interrupted stitches using absorbable suture.
2. Results Intraoperative cystoscopy identified a prostatic rectourethral fistula in 6 cases and a bulbar rectourethral fistula in 15 cases. The orifices of the rectourethral fistula were all along the midline dorsal wall of the posterior urethra (Fig. 2). The 3Fr ureteral catheter was successfully inserted through the rectourethral fistula in each case except one. In that case, methylene blue was used to stain successfully the rectourethral fistula tract. The length of rectourethral fistula averaged
The majority of males born with ARM have a rectourethral fistula. The surgery to correct the fistula usually involves separation of the urinary and gastrointestinal systems. However, the urethra and rectum share a long common wall, and this generates a significant risk of injury to the urethra [1]. Likewise, urethral injury and/or failure to recognize the congenital fistula at the time of initial repair can lead to a recurrent rectourethral fistula [1]. In order to prevent an intraoperative urethral injury, surgeons may tend to dissect closely to the rectum. However, this may increase the risk of incomplete excision of the rectourethral fistula subsequent to diverticulum formation [1,2]. The key to preventing urethral complications is the accurate identification of the rectourethral fistula and its relationship with the urethra. Historically, augmented pressure colostograms, which preoperatively identify the existence and location of rectourethral fistulas, have improved the surgical intervention of rectourethral fistulas [3]. In skilled hands, urologic injuries during the PSARP procedure have dropped dramatically to 3.3% in Peña's group [7]. However, in other groups urologic injuries remain ~ 32%, even when the same technique is used [1]. 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. His group later developed another method in which they first identified and opened the rectourethral fistula. A fine ureteral catheter was then inserted into the tract to label the rectourethral fistula. With the help of cystoscopy, the length of the rectourethral fistula could be calculated and complete excision of fistula could be guaranteed [5]. In contrast, in our study we performed cystoscopy before PSARP and inserted a ureteral catheter from the urethral side. Compared with methods used by Atsuyuki above [5,6], this procedure does not require opening either the rectum or the rectourethral fistula prior to marking the fistula. Using this procedure, we provide surgeons with three
Fig. 2. Cystoscopy shows a bulbar rectourethral fistula (a) and insertion of a 3Fr ureteral catheter (b). asterisk, orifice of fistula.
Please cite this article as: Huang Y, et al, Cystoscopic-assisted excision of rectourethral fistulas in males with anorectal malformations, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.04.002
Y. Huang et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
3
Fig. 3. When the rectum is opened in PSARP, the ureteral catheter labeling the rectourethral fistula can be easily identified (a). The dissection of the fistula can be facilitated by the catheter (b). R, rectum; arrow, rectourethral fistula.
advantages compared with a standard PSARP that does not apply to this maneuver. First, the ureteral catheter labels the fistula such that a surgeon can easily identify the fistula once the rectum is opened. This is especially important when the rectal orifice of the fistula is small or the position of the orifice is more proximal on the rectal anterior wall. Second, marking the fistula helps the surgeon distinguish the margin of the fistula from the surrounding tissue, thereby preventing rupture of the thin wall of the fistula and injury to the urethra during dissection. Third, the ureteral catheter and Foley catheter can mark the junction of the urethra and fistula, which may help avoid an incomplete excision of the fistula. This is especially useful in patients with recurrent rectourethral fistulas which are usually surrounded by scar. We routinely perform preoperative augmented pressure colostograms. However, two patients in this study with symptoms suggestive of a fistula were not diagnosed by colostogram. We think that this may have resulted from obstruction of the fistula by fecal residue in the distal colonic segment. Notably, it has also been reported that the location of a fistula based on colostogram can be somewhat subjective [5]. Thus, we think that a secondary test like cystoscopy to evaluate the existence and location of a rectourethral fistula is necessary for some patients. In our series, we found the length of the rectourethral fistula ranged from 5 to 15 mm, which was similar to previously reported lengths of 5–21 mm [5]. Furthermore, the orifices on the urethral side were all located along the midline dorsal wall of the posterior urethra based upon our cystoscopic exam. In the majority of cases, it takes some time to find the fistula orifice, as it is typically small and the edge is unclear. Therefore, it is useful to use a 3Fr urethral catheter to probe gently any suspected orifice. Because the inner wall of fistula is smooth, the catheter should slide in easily if a fistula does exist. On the contrary, if obvious resistance is encountered, the surgeon should stop attempting to place the catheter to prevent urethral injury. If placement of a ureteral catheter fails, injection of undiluted methylene blue to stain the rectourethral fistula may be helpful. As previously reported, a similar method was successfully applied at our institution to label pyriform sinus fistulas [9]. In this instance, intraoperative endoscopy was performed to detect
the internal orifice on the pharyngeal side. A ureteral catheter or injection of methylene blue was subsequently used to label the fistula. There have been no recurrent pyriform sinus fistulas in the 42 patients in which this method was utilized. Additionally, a preoperative colostogram providing the anatomic relationship between fistula and urethra may help find the orifice. By definitively labeling the rectourethral fistula, this method is effective in enabling complete excision of the rectourethral fistula. Although it has only been applied in PSARP at our institution, it may also be potentially useful in LAARP. Acknowledgements We thank Dr. Zarine Balsara for her English assistance for the manuscript. This study was funded by Shanghai Municipal Commission of Health and Family Planning (20124Y139). References [1] Hong AR, Acuña MF, Peña A, et al. Urologic injuries associated with repair of anorectal malformations in male patients. J Pediatr Surg 2002;37(3):339–44. [2] Alam S, Lawal TA, Peña A, et al. Acquired posterior urethral diverticulum following surgery for anorectal malformations. J Pediatr Surg 2011;46(6):1231–5. [3] Gross GW, Wolfson PJ, Peña A. Augmented-pressure colostogram in imperforate anus with fistula. Pediatr Radiol 1991;21(8):560–2. [4] Koga H, Okazaki T, Yamataka A, et al. Posterior urethral diverticulum after laparoscopic-assisted repair of high-type anorectal malformation in a male patient: surgical treatment and prevention. Pediatr Surg Int 2005;21:58–60. [5] Koga H, Kato Y, Shimotakahara A, et al. Intraoperative measurement of rectourethral fistula: prevention of incomplete excision in male patients with high-/intermediatetype imperforate anus. J Pediatr Surg 2010;45(2):397–400. [6] Yamataka A, Kato Y, Lee KD, et al. Endoscopy-assisted laparoscopic excision of rectourethral fistula in a male with imperforate anus. J Laparoendosc Adv Surg Tech A 2009;19(Suppl. 1):S241–3. [7] Peña A, Devries PA. Posterior sagittal anorectoplasty: important technical considerations and new applications. J Pediatr Surg 1982;17(6):796–811. [8] Georgeson KE, Inge TH, Albanese CT. Laparoscopically assisted anorectal pull-through for high imperforate anus-a new technique. J Pediatr Surg 2000;35:927–31. [9] Sheng Q, Lv Z, Xiao X, et al. Diagnosis and management of pyriform sinus fistula: experience in 48 cases. J Pediatr Surg 2014;49(3):455–9.
Please cite this article as: Huang Y, et al, Cystoscopic-assisted excision of rectourethral fistulas in males with anorectal malformations, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.04.002
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Operative Techniques
Cystoscopic-assisted excision of rectourethral fistulas in males with anorectal malformations Yichen Huang a, Weijue Xu b, Hua Xie a,⁎, Yibo Wu b, Zhibao Lv b, Fang Chen a a b
Department of Urology, Shanghai Children’s Hospital, Shanghai Jiaotong University, Shanghai, China Department of General Surgery, Shanghai Children’s Hospital, Shanghai Jiaotong University, Shanghai, China
a r t i c l e
i n f o
Article history: Received 12 August 2014 Received in revised form 15 March 2015 Accepted 6 April 2015 Available online xxxx Key words: Cystoscopy Rectourethral Fistula Anorectal Malformation
a b s t r a c t Introduction: We report a novel technique to label rectourethral fistulas in males with anorectal malformations who are undergoing posterior sagittal anorectoplasty (PSARP) to facilitate complete excision of the fistula. Methods: Prior to performing PSARP in 21 male patients with rectourethral fistulas, cystoscopy was carried out to identify the orifice of the fistula within the urethra. A 3Fr ureteral catheter with calibrations was then inserted into the orifice to label the fistula. During the PSARP procedure, the rectourethral fistula was dissected to the junction of the urethra, as identified by the presence of the ureteral catheter, and the fistula tract was completely excised. Results: Six prostatic and 15 bulbar rectourethral fistulas were found by cystoscopy. The orifices of the rectourethral fistulas were all located in the midline along the dorsal wall of the posterior urethra. The average length of the rectourethral fistulas was 10 mm (range = 5–15 mm). During the PSARP procedure, the rectourethral fistula could be clearly identified, easily dissected and completely excised. Patients were followed up for 7–24 months. During the length of follow-up, micturition was normal and no urethral complications were found in any of the 21 patients. Conclusion: Intraoperative cystoscopy with placement of a ureteral catheter in the fistula tract facilitates complete excision of rectourethral fistulas in males with anorectal malformations without risking injury to the urethra. © 2015 Elsevier Inc. All rights reserved.
More than 80% of boys born with anorectal malformations (ARM) have a rectourethral fistula [1]. Although significant advances have been achieved in surgical interventions, many children still experience urethral complications which are potentially avoidable. The most commonly reported complications are recurrent rectourethral fistulas (23.3%), urethral injuries (20.2%) and posterior urethral diverticula (17.8%) [2]. Accurate identification of a rectourethral fistula and its relationship with the urethra is important to enable complete excision of the rectourethral fistula and prevent urethral complications. Many methods have been used to identify rectourethral fistulas, including preoperative augmented pressure colostogram [3] and intraoperative endoscopy [4–6]. In this study, we performed cystoscopy and labeled the rectourethral fistula with a ureteral catheter before posterior sagittal anorectoplasty (PSARP). This procedure allows surgeons to easily mark the fistula and thereby facilitates complete excision of the rectourethral fistula without injuring the urethra.
⁎ Corresponding author at: Department of Urology, Shanghai Children’s Hospital, Shanghai Jiaotong University. No 355, Luding Rd, Shanghai, 200062, China. Tel.: +86 18917128147; fax: +86 021 62790494. E-mail address: [email protected] (H. Xie).
1. Methods This study was performed in 21 male patients with ARM and rectourethral fistula who underwent PSARP at our institution from 2011 to 2013. The rectourethral fistula was either diagnosed by preoperative augmented pressure colostogram (19/21) or suspected based upon the presence of stool in the patient’s urine (2/21). The mean age of patients was 7.6 months (range = 6–9 months). All surgeries were performed by the same group of surgeons. An initial descending colostomy was performed in 20/21 patients shortly after birth at our institution. One patient underwent a loop transverse colostomy at another hospital before being transferred to our institution. Before surgery, an augmented pressure colostogram was conducted to confirm the level of rectal atresia and any associated fistulous communication [3] (Fig. 1). The patient was then placed in lithotomy position. Cystoscopy was performed by a urologist. The prostatic urethra, bulbar urethra and bladder neck were carefully examined. A 3Fr ureteral catheter was used to probe any suspected orifice. When a rectourethral fistula did exist, the catheter could be inserted with ease (Fig. 2). In one case, although the initial colostogram indicated the presence of a rectourethral fistula, only the tip of the catheter could be inserted into the suspected orifice. Instead, we injected undiluted methylene blue through the catheter to stain the fistula tract. After cystoscopy, a 6Fr Foley catheter was placed per urethra into the bladder.
http://dx.doi.org/10.1016/j.jpedsurg.2015.04.002 0022-3468/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Huang Y, et al, Cystoscopic-assisted excision of rectourethral fistulas in males with anorectal malformations, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.04.002
2
Y. Huang et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
10 mm (5–15 mm). Notably, preoperative colostogram had identified the presence of a rectourethral fistula in 19/21 patients, and the locations of each fistula were consistent with the results obtained from cystoscopy. All Foley catheters were removed 7 days postoperatively. Patients were followed for 7–24 months postoperatively. In all 21 patients, micturition was normal and no urethral complications were found on follow-up.
3. Discussion
Fig. 1. Preoperative augmented pressure colostogram shows the level of rectal atresia and the rectourethral fistula. R, rectum; Bl, bladder; asterisk, junction of urethra and fistula.
The patient was then changed to prone position, and a standard PSARP procedure was performed [7]. Once the rectum was opened longitudinally along the midline, the catheter labeling the fistula could be observed clearly (Fig. 3). In the single case in which methylene blue was used, the rectourethral fistula tract was visibly stained. The rectourethral fistula was further dissected to the junction of the urethra with help of the catheter. The length of the rectourethral fistula was then measured. Finally, the rectourethral fistula was completely excised and closed with interrupted stitches using absorbable suture.
2. Results Intraoperative cystoscopy identified a prostatic rectourethral fistula in 6 cases and a bulbar rectourethral fistula in 15 cases. The orifices of the rectourethral fistula were all along the midline dorsal wall of the posterior urethra (Fig. 2). The 3Fr ureteral catheter was successfully inserted through the rectourethral fistula in each case except one. In that case, methylene blue was used to stain successfully the rectourethral fistula tract. The length of rectourethral fistula averaged
The majority of males born with ARM have a rectourethral fistula. The surgery to correct the fistula usually involves separation of the urinary and gastrointestinal systems. However, the urethra and rectum share a long common wall, and this generates a significant risk of injury to the urethra [1]. Likewise, urethral injury and/or failure to recognize the congenital fistula at the time of initial repair can lead to a recurrent rectourethral fistula [1]. In order to prevent an intraoperative urethral injury, surgeons may tend to dissect closely to the rectum. However, this may increase the risk of incomplete excision of the rectourethral fistula subsequent to diverticulum formation [1,2]. The key to preventing urethral complications is the accurate identification of the rectourethral fistula and its relationship with the urethra. Historically, augmented pressure colostograms, which preoperatively identify the existence and location of rectourethral fistulas, have improved the surgical intervention of rectourethral fistulas [3]. In skilled hands, urologic injuries during the PSARP procedure have dropped dramatically to 3.3% in Peña's group [7]. However, in other groups urologic injuries remain ~ 32%, even when the same technique is used [1]. 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. His group later developed another method in which they first identified and opened the rectourethral fistula. A fine ureteral catheter was then inserted into the tract to label the rectourethral fistula. With the help of cystoscopy, the length of the rectourethral fistula could be calculated and complete excision of fistula could be guaranteed [5]. In contrast, in our study we performed cystoscopy before PSARP and inserted a ureteral catheter from the urethral side. Compared with methods used by Atsuyuki above [5,6], this procedure does not require opening either the rectum or the rectourethral fistula prior to marking the fistula. Using this procedure, we provide surgeons with three
Fig. 2. Cystoscopy shows a bulbar rectourethral fistula (a) and insertion of a 3Fr ureteral catheter (b). asterisk, orifice of fistula.
Please cite this article as: Huang Y, et al, Cystoscopic-assisted excision of rectourethral fistulas in males with anorectal malformations, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.04.002
Y. Huang et al. / Journal of Pediatric Surgery xxx (2015) xxx–xxx
3
Fig. 3. When the rectum is opened in PSARP, the ureteral catheter labeling the rectourethral fistula can be easily identified (a). The dissection of the fistula can be facilitated by the catheter (b). R, rectum; arrow, rectourethral fistula.
advantages compared with a standard PSARP that does not apply to this maneuver. First, the ureteral catheter labels the fistula such that a surgeon can easily identify the fistula once the rectum is opened. This is especially important when the rectal orifice of the fistula is small or the position of the orifice is more proximal on the rectal anterior wall. Second, marking the fistula helps the surgeon distinguish the margin of the fistula from the surrounding tissue, thereby preventing rupture of the thin wall of the fistula and injury to the urethra during dissection. Third, the ureteral catheter and Foley catheter can mark the junction of the urethra and fistula, which may help avoid an incomplete excision of the fistula. This is especially useful in patients with recurrent rectourethral fistulas which are usually surrounded by scar. We routinely perform preoperative augmented pressure colostograms. However, two patients in this study with symptoms suggestive of a fistula were not diagnosed by colostogram. We think that this may have resulted from obstruction of the fistula by fecal residue in the distal colonic segment. Notably, it has also been reported that the location of a fistula based on colostogram can be somewhat subjective [5]. Thus, we think that a secondary test like cystoscopy to evaluate the existence and location of a rectourethral fistula is necessary for some patients. In our series, we found the length of the rectourethral fistula ranged from 5 to 15 mm, which was similar to previously reported lengths of 5–21 mm [5]. Furthermore, the orifices on the urethral side were all located along the midline dorsal wall of the posterior urethra based upon our cystoscopic exam. In the majority of cases, it takes some time to find the fistula orifice, as it is typically small and the edge is unclear. Therefore, it is useful to use a 3Fr urethral catheter to probe gently any suspected orifice. Because the inner wall of fistula is smooth, the catheter should slide in easily if a fistula does exist. On the contrary, if obvious resistance is encountered, the surgeon should stop attempting to place the catheter to prevent urethral injury. If placement of a ureteral catheter fails, injection of undiluted methylene blue to stain the rectourethral fistula may be helpful. As previously reported, a similar method was successfully applied at our institution to label pyriform sinus fistulas [9]. In this instance, intraoperative endoscopy was performed to detect
the internal orifice on the pharyngeal side. A ureteral catheter or injection of methylene blue was subsequently used to label the fistula. There have been no recurrent pyriform sinus fistulas in the 42 patients in which this method was utilized. Additionally, a preoperative colostogram providing the anatomic relationship between fistula and urethra may help find the orifice. By definitively labeling the rectourethral fistula, this method is effective in enabling complete excision of the rectourethral fistula. Although it has only been applied in PSARP at our institution, it may also be potentially useful in LAARP. Acknowledgements We thank Dr. Zarine Balsara for her English assistance for the manuscript. This study was funded by Shanghai Municipal Commission of Health and Family Planning (20124Y139). References [1] Hong AR, Acuña MF, Peña A, et al. Urologic injuries associated with repair of anorectal malformations in male patients. J Pediatr Surg 2002;37(3):339–44. [2] Alam S, Lawal TA, Peña A, et al. Acquired posterior urethral diverticulum following surgery for anorectal malformations. J Pediatr Surg 2011;46(6):1231–5. [3] Gross GW, Wolfson PJ, Peña A. Augmented-pressure colostogram in imperforate anus with fistula. Pediatr Radiol 1991;21(8):560–2. [4] Koga H, Okazaki T, Yamataka A, et al. Posterior urethral diverticulum after laparoscopic-assisted repair of high-type anorectal malformation in a male patient: surgical treatment and prevention. Pediatr Surg Int 2005;21:58–60. [5] Koga H, Kato Y, Shimotakahara A, et al. Intraoperative measurement of rectourethral fistula: prevention of incomplete excision in male patients with high-/intermediatetype imperforate anus. J Pediatr Surg 2010;45(2):397–400. [6] Yamataka A, Kato Y, Lee KD, et al. Endoscopy-assisted laparoscopic excision of rectourethral fistula in a male with imperforate anus. J Laparoendosc Adv Surg Tech A 2009;19(Suppl. 1):S241–3. [7] Peña A, Devries PA. Posterior sagittal anorectoplasty: important technical considerations and new applications. J Pediatr Surg 1982;17(6):796–811. [8] Georgeson KE, Inge TH, Albanese CT. Laparoscopically assisted anorectal pull-through for high imperforate anus-a new technique. J Pediatr Surg 2000;35:927–31. [9] Sheng Q, Lv Z, Xiao X, et al. Diagnosis and management of pyriform sinus fistula: experience in 48 cases. J Pediatr Surg 2014;49(3):455–9.
Please cite this article as: Huang Y, et al, Cystoscopic-assisted excision of rectourethral fistulas in males with anorectal malformations, J Pediatr Surg (2015), http://dx.doi.org/10.1016/j.jpedsurg.2015.04.002
