# Recto-vestibular Fistula — GCMD Library living collection

Everything in the library about recto-vestibular fistula — built automatically from dossiers that name it.

Updated: n/a · 3 episodes · 37 cited statements

## Episodes
### Surgical Management
- [Update Course Rewind: Perineal Body Sparing PSARP 2023](https://origin-library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857) — video · 2:55 · [machine version](https://origin-library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857.md)

### Evidence & Research
- [2025 Pediatric Surgery Update Course - Updates in Colorectal: Debunking Dogma](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899) — video · 30:29 · [machine version](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899.md)

### Case-Based Learning
- [Posterior Sagittal Anorectaplasty in a Female: Pediatric Colorectal...](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095) — video · 1:28:20 · [machine version](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095.md)

## Chapters
- [0:00](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=0) Initial examination and discovery of absent vaginal lumen (Ep 1)
- [7:03](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=423) Decision to proceed with rectal mobilization and surgical technique (Ep 1)
- [15:16](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=916) Cystoscopy findings and neovaginal planning (Ep 1)
- [21:46](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=1306) Expert consultation on neovaginal reconstruction timing and technique (Ep 1)
- [30:15](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=1815) Dissection of rectourethral plane and preparation for laparotomy (Ep 1)
- [40:30](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=2430) Laparoscopic findings and gynecologic consultation (Ep 1)
- [46:23](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=2783) Sigmoid neovagina creation and uterine preservation decision (Ep 1)
- [53:12](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=3192) Neovaginal pull-through and perineal reconstruction (Ep 1)
- [66:53](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=4013) Muscle complex identification and anoplasty completion (Ep 1)
- [80:11](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=4811) Final reconstruction and post-operative planning (Ep 1)
- [0:00](https://origin-library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=0) Introduction and Case Presentation (Ep 2)
- [0:45](https://origin-library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=45) Perineal Body Sparing PSARP Techniques (Ep 2)
- [2:00](https://origin-library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=120) Benefits and Summary (Ep 2)
- [2:35](https://origin-library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=155) Closing (Ep 2)
- [0:02](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=2) Timing of PSARP for recto-vestibular fistula: neonatal vs delayed repair (Ep 3)
- [9:09](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=549) Perineal body-preserving PSARP technique and outcomes (Ep 3)
- [15:49](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=949) Postoperative anal dilations: questioning the paradigm (Ep 3)
- [19:32](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1172) Timing of pull-through for Hirschsprung disease (Ep 3)
- [23:05](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1385) Intra-sphincteric Botox injection at Hirschsprung pull-through (Ep 3)
- [26:26](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1586) Co-occurrence of anorectal malformation and Hirschsprung disease (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- In absent vagina situations with recto-vestibular fistula, the urethra is characteristically enlarged — Marc Levitt (clinical) [Ep 1 · 19:47](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=1187)
- In babies this small, MRI has difficulty delineating uterine and ovarian structures — Marc Levitt (clinical) [Ep 1 · 3:21](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=201)
- Train-of-four box from anesthesia machine is a less expensive alternative to dedicated nerve stimulator for muscle mapping — Marc Levitt (clinical) [Ep 1 · 7:47](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=467)
- Lateral dissection defines the anterior plane in rectal mobilization - first step is to establish clean lateral plane — Marc Levitt (clinical) [Ep 1 · 15:16](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=916)
- In congenital cervical agenesis, there is no evidence that retaining the uterus and connecting to vagina enables successful live births — Don (clinical) [Ep 1 · 44:03](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=2643)
- Uterus without cervix has risk of pyometra and ascending infection when connected to outflow tract — Don (clinical) [Ep 1 · 44:03](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=2643)
- In surgeon's series of recto-vestibular fistula with no vagina (8 patients), only one had imperforate hymen; none of the others had uterus or fallopian tubes — Don (epidemiological) [Ep 1 · 28:50](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=1730)
- Sigmoid colon pulled down to anus will not function as rectum - lacks same storage qualities and physiologic properties — Don (clinical) [Ep 1 · 28:50](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=1730)
- Best time to create neovagina is when rectum has been mobilized; waiting creates scarred perineum making later reconstruction more difficult — Marc Levitt (opinion) [Ep 1 · 48:12](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=2892)
- Standard neovaginal length in infant is 7-8 centimeters based on normal vaginal length in babies — Marc Levitt (clinical) [Ep 1 · 65:08](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=3908)
- Surgeon prefers colon over small bowel for neovagina because small bowel mesentery is more tenuous and colon has more robust blood supply — Marc Levitt (opinion) [Ep 1 · 59:42](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=3582)
- Surgeon does not dilate neovaginas post-operatively, anticipating some patients will need minor revision but avoiding torture of vaginal dilations — Marc Levitt (opinion) [Ep 1 · 69:37](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=4177)
- Six months after breast budding is appropriate timing for pelvic ultrasound and vaginoscopy to assess Müllerian structures and menstrual patency — Marc Levitt (clinical) [Ep 1 · 69:37](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=4177)
- Neovagina should be tacked to pelvic fascia or posterior bladder to prevent prolapse and ensure it grows with the patient — Marc Levitt (clinical) [Ep 1 · 68:53](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=4133)
- When fat is visible during rectal dissection, surgeon can safely dissect closer to the bowel wall — Marc Levitt (clinical) [Ep 1 · 35:07](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=2107)
- Staple lines should be removed from neovaginal segment rather than left in place — Marc Levitt (opinion) [Ep 1 · 49:17](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=2957)
- In this patient population, there is thick wall between rectum and urethra in absent vagina situations — Marc Levitt (clinical) [Ep 1 · 20:28](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=1228)
- Surgeon would not perform independent examination under anesthesia in straightforward newborn primary anorectal malformation case, but would examine at time of repair — Marc Levitt (opinion) [Ep 1 · 27:20](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=1640)
- Two variations of perineal body sparing PSARP have been published in the last 6 months, one from Boston and one from Washington DC. — Steven Lee (clinical) [Ep 2 · 1:08](https://origin-library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=68)
- The Boston technique involves a slight posterior sagittal extension of the incision. — Steven Lee (clinical) [Ep 2 · 1:26](https://origin-library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=86)
- These techniques aim to spare the perineal body and preserve long-term gynecologic function for female patients. — Steven Lee (clinical) [Ep 2 · 1:30](https://origin-library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=90)
- The perineal body is important for sexual function and obstetric outcomes in the future. — Steven Lee (clinical) [Ep 2 · 1:38](https://origin-library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=98)
- The Washington DC technique uses an incision just through the sphincter alone, preserving the perineal body skin in its entirety. — Steven Lee (clinical) [Ep 2 · 1:49](https://origin-library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=109)
- For patients undergoing dilations who are not diverted, the perineal body seeing stool right away is a setup for post-operative infection. (clinical) [Ep 2 · 2:00](https://origin-library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=120)
- When dilating a recto-vestibular fistula preoperatively, dilate only to 7 Hegar to decrease potential scarring along the tract for future PSARP. — Jamie Harris (clinical) [Ep 3 · 2:33](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=153)
- Preoperative dilations seem to be more tolerated than postoperative dilations; families are worried they will hurt their babies and the repair. (opinion) [Ep 3 · 17:00](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1020)
- Families who are competent with rectal irrigations before Hirschsprung pull-through will be more comfortable performing irrigations after pull-through, which can save the baby's life by treating enterocolitis early. — Jamie Harris (opinion) [Ep 3 · 21:03](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1263)
- Families who are really good at irrigations start treatment for enterocolitis before they ever call the surgeon. (clinical) [Ep 3 · 21:36](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1296)
- Longer aganglionic segments in Hirschsprung disease affect timing of pull-through; patients who cannot be adequately decompressed at home may require earlier intervention to prevent enterocolitis or perforation. (clinical) [Ep 3 · 21:55](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1315)
- Absent ganglion cells in fistula tissue does not necessarily mean Hirschsprung disease, as fistula tissue is not physiologic tissue. (clinical) [Ep 3 · 28:03](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1683)
- Complex anorectal malformation patients with chromosomal anomalies who are not responding to laxatives or enemas are worth working up for Hirschsprung disease. (clinical) [Ep 3 · 28:38](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1718)
- Perineal body-preserving PSARP is basically the same technique one would use for a bulbar fistula but applied to a vestibular fistula. — Nelson Rosen (clinical) [Ep 3 · 11:04](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=664)
- For perineal body-preserving PSARP, the key is to really clean up the lateral planes before coming around the front, mobilizing the sides and staying on the bowel wall before deciding to come through the common plane. — Nelson Rosen (clinical) [Ep 3 · 11:32](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=692)
- When starting perineal body-preserving PSARP, it is acceptable to go a little bit into the perineal body on the front and a little bit behind it in the back to make the working incision not the tightest pinhole, while still keeping the perineal body largely intact. — Nelson Rosen (clinical) [Ep 3 · 11:45](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=705)
- If lost in the anatomy during perineal body-preserving PSARP, it is easy to convert to a standard PSARP by extending the incision. — Jamie Harris (clinical) [Ep 3 · 13:23](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=803)
- Preoperative fistula dilation is a controlled tear when the fistula starts as a pinhole, not true stretching; dilate only as big as needed and then leave it alone until definitive repair. — Nelson Rosen (clinical) [Ep 3 · 8:41](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=521)
- Heineke-Mikulicz stricturoplasty is a minimally invasive surgical backup option for neo-anal stricture if not performing routine postoperative dilations. (clinical) [Ep 3 · 18:26](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1106)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Total body prep from nipples to toes is standard for these patients, allowing flexibility to flip between supine and prone positions — Todd Ponsky summarizing the discussion [Ep 1 · 2:10](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=130)
- MRI has limited ability to determine presence of vaginal lumen in very young patients unless there is clear hematocolpos or hydrocolpos — Marc Levitt summarizing the discussion [Ep 1 · 82:15](https://origin-library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=4935)
- One study has 6 patients and the other has 4 patients. — Em Gootee summarizing the discussion [Ep 2 · 1:17](https://origin-library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=77)
- The techniques are similar but slightly different. — Em Gootee summarizing the discussion [Ep 2 · 1:20](https://origin-library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=80)
- Perineal body sparing techniques can reduce post-operative infection risks in patients undergoing dilations. — Em Gootee summarizing the discussion [Ep 2 · 2:12](https://origin-library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=132)
- Two 2021 studies (one NISQIP, one PCPLC) showed no difference in wound complications, re-operations, or readmissions between early PSARP (less than 7-14 days) and delayed PSARP (6 weeks to 8 months) for female perineal or recto-vestibular fistulas. — Jamie Harris summarizing the discussion [Ep 3 · 5:08](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=308)
- Perineal body-preserving PSARP first publication in 2023 showed at one-year follow-up no dehiscence, no prolapse, only 13% of patients required revision of anal stenosis, and two-thirds of patients went home on postoperative day one. — The host summarizing the discussion [Ep 3 · 10:22](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=622)
- Perineal body-preserving PSARP does not add operative time compared to standard PSARP, which is important in neonates to minimize anesthetic time. — Jamie Harris summarizing the discussion [Ep 3 · 14:03](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=843)
- Postoperative anal dilations after PSARP are associated with parental anxiety, PTSD for both patients and caregivers, and post-traumatic stress symptoms in families. — The host summarizing the discussion [Ep 3 · 16:31](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=991)
- Spanish single-center study showed that children adequately sized at initial post-PSARP appointment did not receive dilations, while undersized children did; outcomes were similar between groups. — The host summarizing the discussion [Ep 3 · 17:19](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1039)
- Single-center review in children under 2 years showed half received dilations and half did not; 2 children in each group required re-operation for neo-anal stricture, and about 15% in each group required Heineke-Mikulicz stricturoplasty. — The host summarizing the discussion [Ep 3 · 18:01](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1081)
- 2021 PCPLC retrospective study of Hirschsprung pull-through showed no difference in preoperative enterocolitis, postoperative enterocolitis, or fecal incontinence between neonatal pull-through (median 11 days) and delayed primary pull-through (median 98 days). — Nelson Rosen summarizing the discussion [Ep 3 · 20:28](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1228)
- Some data suggests maybe better continence in the delayed Hirschsprung pull-through group, but studies have been underpowered. — The host summarizing the discussion [Ep 3 · 22:39](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1359)
- Multi-center retrospective study published in 2022 showed 24% of Hirschsprung patients received at least one Botox injection. — Nelson Rosen summarizing the discussion [Ep 3 · 23:40](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1420)
- Cincinnati Children's prospective study (2020-2024, unpublished) found decreased risk of enterocolitis within 31 days after pull-through in patients who received Botox (30% vs 50%). — Nelson Rosen summarizing the discussion [Ep 3 · 23:58](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1438)
- Cincinnati Children's prospective study found patients who received Botox at time of pull-through had higher risk of diaper rash (60%). — Nelson Rosen summarizing the discussion [Ep 3 · 24:23](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1463)
- Early work from Sam Nurko's group in Boston used weight-based Botox dosing up to a maximum of 100 units for Hirschsprung patients. — Nelson Rosen summarizing the discussion [Ep 3 · 24:58](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1498)
- The rate of co-occurrence of Hirschsprung disease and anorectal malformation is approximately 2% based on Pena's series, though some papers show as high as 3-4% and others less than 1%. — The host summarizing the discussion [Ep 3 · 27:03](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1623)
- Single-center PCPLC study found ganglion cells in 90% of rectal fistula specimens taken during PSARP, with hypoganglionosis or absent ganglion cells in the rest. — The host summarizing the discussion [Ep 3 · 27:39](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1659)
- PCPLC database review of approximately 1700 patients showed that patients with both anorectal malformation and Hirschsprung disease tend to have chromosomal anomalies, particularly trisomy 21. — The host summarizing the discussion [Ep 3 · 28:13](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1693)

## Changelog
- Sep 11: 3 items added automatically

---
Educational content from recorded physician discussions — not medical advice. Cite the canonical URL or the ?t= deep link. Policy: https://origin-library.globalcastmd.com/ai