Laparoscopic-Assisted Anorectoplasty for Rectovestibular Fistula: A Comparison Study with Anterior Sagittal Anorectoplasty

Background Posterior or anterior sagittal anorectoplasty (ASARP) is the mainstream for correcting rectovestibular fistula (RVF). However, the intermediate RVF has the potential risk of wound complications when applying ASARP due to its high rectal pouch, long fistula tract, and difficulty separating the rectum and vagina. We developed laparoscopic-assisted anorectoplasty (LAARP) for surgical correction of RVF, which has acceptable preliminary outcomes. The purpose of this study is to evaluate the safety and efficacy of LAARP in comparison with ASARP for patients with RVF. Materials and Methods Twenty-five patients with RVF who underwent LAARP between October 2017 and December 2020 were retrospectively reviewed. The outcomes were compared with 43 patients who underwent ASARP between April 2015 and August 2018. The age, weight at operation, sacral ratio, operative time, and postoperative hospital stay were evaluated. The results were assessed for complications, perineum appearance, and bowel function. Results The two groups were comparable in terms of demographics. The median operative time of the LAARP group was significantly longer than that of the ASARP group (113 vs. 95 minutes; p = 0.015). The mean length of the resected rectum in the LAARP group was also longer than that in the ASARP group (6.75 ± 5.07 vs. 3.31 ± 3.06 cm; p = 0.001). Compared with the LAARP group, complications in the ASARP group were more frequent (4.0 vs. 27.9%, p = 0.036). No intraoperative or postoperative wound-related complications occurred in the LAARP group. However, in the ASARP group, one patient had an intraoperative vaginal injury and four had postoperative anastomosis-related complications. The incidence of redo operation in the ASARP group was significantly higher than that in the LAARP group (p = 0.000). Cosmetic satisfaction was higher in the LAARP group (96.0 vs. 76.7%; p < 0.05). In terms of voluntary bowel movement, soiling, and constipation, the LAARP group had similar results compare with the ASARP group. Conclusion The LAARP technique has shown several unique strengths in treating intermediate type RVF, including lower risks of complications, and minimal muscular injury, with a comparable bowel function.

National Medical Research Center for Children’s Health

Introduction. Anorectal malformations are one of the most numerous groups of proctologic pathology in children. The incidence is 1 per 5,000 live births. Perineal ultrasound, distal colostography, and MRI of the pelvic organs and sacrococcygeal region are used to clarify the anatomico-topographic features of the malformation and identify concomitant malformations (presacral masses, distal spinal cord pathology). This article presents a clinical case of surgical treatment of an 11-year-old girl who underwent primary surgery for anorectal malformation with rectovestibular fistula in infancy. In the postoperative period for 10 years, the parents practically did not carry out rehabilitation therapy. These factors led to persistent decompensation of the lower intestine in the form of a giant megarectum, which required repeated anorectoplasty with resection of pathologically dilated parts of the intestinal tube. The article presents description of the repeated surgery with intraoperative electromyoidentification of the perineal muscles, data of follow-up 9 months after the repeated anorectoplasty with instrumental diagnostic methods (irrigography, functional study of the closing apparatus of the rectum).Discussion. This clinical observation illustrates complications following surgical treatment of anorectal malformation with rectovestibular fistula. Lack of intraoperative electromyoidentification of the muscles during primary anorectoplasty often resulted in ectopia of the neoanus relative to the center of the perineal muscle center. This circumstance was one of the causes of persistent chronic constipation in the postoperative period.Conclusion. The use of electromyostimulation during primary proctoplasty for reliable determination of the sphincter-levator complex topography is mandatory. Long sequential rehabilitation in the postoperative period including neoanus bougienage, provision of regular full defecation, physiotherapeutic treatment, as well as regular follow-up examination in the in-patient department is also an integral part of the treatment.

Anorectal Malformation with Rectovestibular Fistula and Vaginal Agenesis: Usage of Rectovestibular Fistula as a Neovagina Followed by PSARP with Preservation of the Anal Sphincter

Anorectal malformation with rectovestibular fistula associated with vaginal agenesis is rare. We report on a child in whom this combination was diagnosed at the age of 1 year. After creation of a divided descending colostomy, we chose to leave the rectum-rectovestibular fistula to function as a neovagina, while the sigmoid colon was relocated via modified posterior sagittal anorectoplasty. The colostomy was closed 6 months after the main surgery. After a follow-up of 3 years, the patient is continent for stool and urine. The introitus of the neovagina appears wide and easy to explore. We conclude that our surgical approach may be a good option for these children.

PRIMARY PROCEDURE FOR RECTO-VESTIBULAR FISTULA IN FEMALE CHILDREN: AN EARLY EXPERIENCE AT KHYBER TEACHING HOSPITAL PESHAWAR.

Background: Recto-vestibular fistula is the most common variant of Anorectal malformation in female children. Traditional management of this entity is a three stages procedure i.e. colostomy, PSARP, and colostomy closure. The aim of this study was to manage these patients by a primary definitive surgical procedure without colostomy and to know the procedure feasibility, cost effectiveness, complications, safety and short term functional outcome. Materials and method: Results: A total of 40 female children fulfilling inclusion criteria of the study were included. Age range was 28 days to 8 months. No mortality noted during study period. Mean operative time was 50±15 minutes. Mean Hospital stay in days was 6.65.Procedure related complications were recorded as wound infection 5(12.5%), wound dehiscence 1 (2.5%), posterior vaginal wall injury 5(12.5%).Overall parental satisfaction regarding procedure was 92.5%. Conclusion: Primary single stage procedure either by PSARP or ASARP for the correction of Rectovestibular fistula in female children of ARM was less traumatic to children, acceptable to their parents, having cost effectiveness for poor socioeconomic parents and encouraging functional outcome.

Association of the rectovestibular fistula with MRKH Syndrome and the paradigm shift in the management in view of the future uterine transplant

Uterine transplantation in Mayer-Rokitansky-Küster-Hauser (MRKH) patients with absolute uterine function infertility have added a new dimension and paradigm shift in the management of females born with rectovestibular fistula coexisting with vaginal agenesis. The author reviewed the relevant literature of this rare association, the popular and practical classifications of genital malformations that the gynecologists use, the different vaginal reconstruction techniques, and try to know what shall serve best in this small cohort of these patients lest they wish to go for uterine transplantation in future.

A modified saggital access in a H-type rectovestibular fistula

A rectovestibular / rectovaginal fistula with a normally formed anus, so-called H-type (H-type fistula), is rather rare anorectal malformation which causes a serious problem for surgical correction of the defect. A surgical correction in infancy is associated with technical difficulties because of specific anatomical relationships and perineum topography in this age group. Thus, an improved surgical access which allows to get good anatomical and functional results and a worthy quality of life in such patients in future is a relevant issue. The authors describe a clinical case of successful treatment of H-type rectovestibular fistula with improved perineal access in a 1-year old child.