# Rectourethral Fistula — GCMD Library living collection

Everything in the library about rectourethral fistula — built automatically from dossiers that name it.

Updated: n/a · 4 episodes · 153 cited statements

## Episodes
### Fundamentals
- [ARMs in Neonates: Pediatric Colorectal Controversies 2014](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100) — video · 1:45:12 · [machine version](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100.md)

### Surgical Management
- [Laparoscopic Surgery for Male Imperforate Anus and Rectourethral Fistula:...](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425) — video · 25:00 · [machine version](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425.md)
- [Tricks - Imperforate Anus and Rectourethral Fistula](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631) — video · 45:32 · [machine version](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631.md)
- [Imperforate Anus & Rectourethral Fistula Technique & Discussion: Difficult Cases](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054) — video · 25:05 · [machine version](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054.md)

## Chapters
- [0:00](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=0) Introduction and Fistula Measurement Technique Overview (Ep 1)
- [3:08](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=188) Prostatic Fistula Case Demonstration (Ep 1)
- [6:00](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=360) Bulbar Fistula Technique and Results (Ep 1)
- [10:51](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=651) Faculty Discussion: Technical Considerations and Approach Selection (Ep 1)
- [0:00](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=0) Laparoscopic repair of imperforate anus with rectourethral fistula: fistula measurement technique (Ep 2)
- [10:51](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=651) Faculty discussion: colostomy placement and laparoscopic approach for anorectal malformations (Ep 2)
- [19:30](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1170) Continued discussion: technical considerations and patient selection for laparoscopic ARM repair (Ep 2)
- [25:51](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1551) Thoracoscopic TEF repair: partial fistula division technique (Ep 2)
- [35:37](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=2137) Faculty discussion: TEF repair techniques and clip complications (Ep 2)
- [0:00](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=0) Introduction and Fistula Measurement Technique Overview (Ep 3)
- [3:08](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=188) Prostatic Fistula Case Demonstration (Ep 3)
- [6:04](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=364) Bulbar Fistula Technique and Key Modifications (Ep 3)
- [9:23](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=563) Results and Outcomes (Ep 3)
- [10:51](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=651) Faculty Discussion: Technique Applicability and Approach Selection (Ep 3)
- [0:00](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=0) Introduction and Newborn Examination Principles (Ep 4)
- [7:04](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=424) Male Perineal Fistula Cases and Surgical Timing (Ep 4)
- [14:27](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=867) Technical Considerations for Male Perineal Fistula Repair (Ep 4)
- [22:39](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=1359) Timing of Repair and Anesthesia Considerations (Ep 4)
- [30:24](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=1824) Trans-scrotal Fistula and Radiologic Evaluation (Ep 4)
- [41:00](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=2460) Surgical Positioning and Avoiding Urethral Injury (Ep 4)
- [47:10](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=2830) Female Perineal Fistula and Perineal Body Assessment (Ep 4)
- [59:40](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=3580) Vaginal Delivery After ARM Repair (Ep 4)
- [68:01](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=4081) Anterior Ectopic Anus and When Not to Operate (Ep 4)
- [74:45](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=4485) Complex Female Anatomy: Absent Vagina and H-type Fistula (Ep 4)
- [80:10](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=4810) Newborn Workup: Cardiac and Associated Anomalies (Ep 4)
- [87:33](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=5253) Sacral Evaluation and Cross-table Lateral Films (Ep 4)
- [91:51](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=5511) Colostomy Technique: Incision Placement and Approach (Ep 4)
- [97:28](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=5848) Loop Versus Divided Stoma and Stoma Positioning (Ep 4)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- In rectourethral fistula repair, dissection must extend to the red line (urethral orifice) to prevent residual fistula, while avoiding injury to nerves, prostate, urethra, and sphincters. — Yamataka (clinical) [Ep 1 · 0:21](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=21)
- A novel technique measures fistula length using a calibrated catheter, allowing the surgeon to know exactly how far to safely dissect distally for complete cyst excision. — Yamataka (clinical) [Ep 1 · 0:33](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=33)
- In a series of 29 male patients with imperforate anus, 23 had rectourethral fistula (14 prostatic, 9 bulbar) and were studied using the new measurement technique. — Yamataka (epidemiological) [Ep 1 · 0:51](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=51)
- During laparoscopic fistula dissection, a fine flexible colonoscope inserted into the anterior rectal wall allows both the fistula orifice and the level of laparoscopic dissection to be observed intraluminally. — Yamataka (clinical) [Ep 1 · 1:52](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=112)
- A fine catheter with calibration is inserted through the fistula opening by the laparoscopic surgeon while another surgeon performing cystoscopy observes how far it emerges at or near the verumontanum, allowing measurement of the inside length of the fistula. — Yamataka (clinical) [Ep 1 · 2:37](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=157)
- If the length of the residual fistula is longer than 5 millimeters, the rectal end is further dissected toward the urethra using mucosectomy to prevent injury to the prostate and urethra. — Yamataka (clinical) [Ep 1 · 4:27](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=267)
- The dissection procedure is repeated until the length of the residual fistula is shorter than or equal to 5 millimeters, then the fistula is ligated, tied, and excised. — Yamataka (clinical) [Ep 1 · 4:57](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=297)
- For bulbar fistula repair, it is very important to obtain a clear surgical field of the deep pelvic floor; this is achieved through use of a tube cystostomy which decompresses the bladder and opens up a clear view. — Yamataka (clinical) [Ep 1 · 6:16](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=376)
- Trocar position for rectal bulbar fistula differs from prostatic fistula in that right and left trocars are placed much closer to the telescope, which is key for bulbar fistula repair. — Yamataka (clinical) [Ep 1 · 6:49](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=409)
- A new device allows the telescope to be adjusted to face any direction from 0 to 120 degrees intraoperatively, allowing the surgeon freedom to choose the best view without disrupting dissection. — Yamataka (clinical) [Ep 1 · 7:10](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=430)
- Despite increased difficulty in handling forceps with closer trocar positioning, it allows the tips of the forceps to reach deeper and to reach the bulbar urethra, which is located deep in the pelvis. — Yamataka (clinical) [Ep 1 · 7:32](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=452)
- After the fistula is tied, a catheter is again inserted until it gently probes the tied fistula, allowing the surgeon to reconfirm that the residual fistula length is shorter than or equal to 5 millimeters. — Yamataka (clinical) [Ep 1 · 8:30](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=510)
- In the first 8 cases, initial measurements of rectal to urethral orifice showed fistula lengths of 13, 15, 12, 10, 15, 21, 10, and 5 millimeters respectively; 7 cases required further dissection until the fistula was ≤5 mm, but case 8 did not require further dissection. — Yamataka (epidemiological) [Ep 1 · 9:25](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=565)
- During cystoscopy, normal saline refluxed into the pelvic floor through the fistula in 6 cases (indicating a large fistula), but there was no reflux in 2 cases (indicating a very narrow fistula). — Yamataka (clinical) [Ep 1 · 9:48](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=588)
- All 23 cases were well after mean follow-up of 2 years, with no evidence of diverticular formation owing to residual fistula on voiding cystourethrography or MRI. — Yamataka (epidemiological) [Ep 1 · 10:10](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=610)
- All dissections were uncomplicated and postoperative courses were unremarkable. — Yamataka (epidemiological) [Ep 1 · 10:20](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=620)
- The residual fistula from rectal site to urethral side is much longer than expected. — Yamataka (clinical) [Ep 1 · 10:28](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=628)
- The new technique measuring the exact length of the fistula facilitates safe and complete excision of the fistula, reducing the risk of postoperative diverticulum formation due to incomplete fistula excision. — Yamataka (opinion) [Ep 1 · 10:37](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=637)
- For prostatic fistula dissection, if the laparoscopic surgeon has training in fundamental techniques like gallbladder removal, they can perform the procedure. — Yamataka (opinion) [Ep 1 · 13:10](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=790)
- The key for dissection of the fistula is decompression of the bladder; if the laparoscopic surgeon's technique is not good enough, inserting a suprapubic catheter first for complete decompression provides a good view of the pelvic floor. — Yamataka (clinical) [Ep 1 · 13:31](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=811)
- For bulbar fistula dissection, a laparoscopic surgeon needs 5 to 10 cases of prostatic fistula experience before they can challenge bulbar fistula. — Yamataka (opinion) [Ep 1 · 14:32](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=872)
- For bulbar fistula, the trocar position must be very close to the telescope; otherwise the tip of the instrument cannot reach the deep side of the pelvis or the bulbar fistula. — Yamataka (clinical) [Ep 1 · 14:43](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=883)
- Traction sutures (2 to 3) using laparoscopic hair closure needles are used to bring the bladder up during the procedure. — Yamataka (clinical) [Ep 1 · 15:49](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=949)
- Right transverse colostomy is preferred because sigmoid colostomy can fix the rectum and colon, requiring takedown of the sigmoid colostomy to achieve enough length for pull-through of the distal end of the fistula. — Yamataka (opinion) [Ep 1 · 16:24](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=984)
- If sigmoid colostomy is done very proximal in the sigmoid or at the descending colon-sigmoid junction, there will be enough length to do a pull-through even for a high fistula. (opinion) [Ep 1 · 17:19](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1039)
- Laparoscopy can be used to help make the initial colostomy, allowing the surgeon to see exactly where they are. — Jose (clinical) [Ep 1 · 18:00](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1080)
- A left lower quadrant transverse incision can be made to pull out the sigmoid and determine which end is which, then go proximal for colostomy placement. (clinical) [Ep 1 · 18:18](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1098)
- Transverse colostomy has too many problems including urine absorption, infection, and prolapse. — Sherif Emil (opinion) [Ep 1 · 18:37](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1117)
- With sigmoid colostomy on the left side, it is possible to place ports and work around the stoma without having to take it down for deep pelvic dissection. — Jose (clinical) [Ep 1 · 19:17](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1157)
- With closer midline port positioning for bulbar fistulas, sigmoid colostomy location becomes less of an issue. — Jose (opinion) [Ep 1 · 19:42](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1182)
- Sigmoid colostomy on the left side can be an obstacle for inserting trocars. — Yamataka (opinion) [Ep 1 · 19:57](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1197)
- With sigmoid colostomy, you can go in the left upper quadrant and go around lateral to the colostomy; it is not an issue. (clinical) [Ep 1 · 20:10](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1210)
- For prostatic or bladder neck fistula, the dissection can be done without the measurement technique and still get very close to the end of the fistula. (opinion) [Ep 1 · 20:26](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1226)
- If the laparoscopic surgeon is familiar with anorectal malformation operations, the measurement technique may not be needed, but for bulbar fistula the procedure is still needed. — Yamataka (opinion) [Ep 1 · 20:40](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1240)
- The laparoscopic approach for bulbar fistula is far more difficult and more dangerous; the technique described is extremely complicated for the average pediatric surgeon, and the PSARP technique is easy for those patients. (opinion) [Ep 1 · 21:06](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1266)
- There is no convincing data that the laparoscopic approach results in any better outcomes for bulbar fistulas than PSARP does. (opinion) [Ep 1 · 21:20](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1280)
- The reason for sticking to laparoscopic procedure even for bulbar fistula is to avoid cutting the anal sphincter and damaging the muscle and nerves for sphincters. — Yamataka (opinion) [Ep 1 · 21:32](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1292)
- Getting a good fistulagram at the beginning is critical; if a good view of the fistula cannot be obtained, the study should be repeated. — Yamataka (clinical) [Ep 1 · 22:13](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1333)
- Before operation, colonoscopy can be performed through the transverse colostomy if there is doubt whether the patient has a fistula; cystoscopy can also be done, and sometimes a combination of colonoscopy and cystoscopy is used if the colostogram does not show nice anatomy of the fistula. — Yamataka (clinical) [Ep 1 · 22:49](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1369)
- For many surgeons, the laparoscopic approach is helpful for high fistulas, but PSARP is still the way to think for low fistulas; the key is deciding beforehand which approach to use. (opinion) [Ep 1 · 23:22](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1402)
- Combining VCUG and colostogram at the same time by putting dye in from both sides usually allows the fistula to be seen clearly. (clinical) [Ep 1 · 23:41](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1421)
- It is very important to have an empty bladder when doing laparoscopic anorectal malformation repair. (clinical) [Ep 1 · 23:51](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1431)
- Sometimes when a Foley catheter is placed at the beginning of the case, it goes into the fistula and into the rectum rather than the bladder, and this may not be discovered until the middle of the operation. (clinical) [Ep 1 · 24:04](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1444)
- It is probably a good idea to cystoscope all anorectal malformation patients at the beginning of the case to make sure the catheter is actually in the bladder before starting. (opinion) [Ep 1 · 24:22](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1462)
- When performing cystoscopy, saline must be injected; for bladder decompression, a suprapubic catheter is needed, otherwise the bladder will be filled with saline and the pelvic floor cannot be seen. — Yamataka (clinical) [Ep 1 · 24:33](https://origin-library.globalcastmd.com/watch/laparoscopic-surgery-for-male-imperforate-anus-and-rectourethral-fistula-425?t=1473)
- Dissection of the rectourethral fistula must extend to a specific anatomical landmark (the 'red line') to prevent residual fistula without injuring nerves, prostate, urethra, and sphincters. (clinical) [Ep 3 · 0:21](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=21)
- The novel technique measures the length of the fistula, allowing the surgeon to know exactly how far to safely dissect distally for complete fistula excision. (clinical) [Ep 3 · 0:33](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=33)
- In the series, 23 of 29 male patients with imperforate anus had rectourethral fistula: 1 vesical, 14 prostatic, 9 bulbar, and 5 with no fistula. (epidemiological) [Ep 3 · 0:51](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=51)
- A fine flexible colonoscope inserted into the anterior rectal wall allows both the fistula orifice and the level of laparoscopic dissection to be observed intraluminally. (clinical) [Ep 3 · 1:52](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=112)
- A fine catheter with calibration is inserted through the fistula opening by the laparoscopic surgeon while another surgeon performing cystoscopy observes how far it emerges at or near the verumontanum, allowing measurement of the inside length of the fistula. (clinical) [Ep 3 · 2:37](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=157)
- If the length of the residual fistula is longer than 5 millimeters, the rectal end is further dissected toward the urethra using mucosectomy to prevent injury to the prostate and urethra. (clinical) [Ep 3 · 4:28](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=268)
- The measurement and dissection procedure is repeated until the length of the residual fistula is shorter than or equal to 5 millimeters, then the fistula is ligated, tied, and excised. (clinical) [Ep 3 · 4:57](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=297)
- For bulbar fistula, it is very important to obtain as clear a surgical field of the deep pelvic floor as possible through use of suprapubic tube cystostomy, which decompresses the bladder and opens up a clear view. (clinical) [Ep 3 · 6:16](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=376)
- Trocar position for bulbar fistula differs from prostatic fistula in that right and left trocars are placed much closer to the telescope, which is key for bulbar fistula. (clinical) [Ep 3 · 6:49](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=409)
- An adjustable telescope device allows the view to be adjusted from 0 to 120 degrees intraoperatively, giving the surgeon freedom to choose the best view without disrupting dissection. (clinical) [Ep 3 · 7:10](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=430)
- Despite increased difficulty in handling forceps with the modified trocar position, it allows the tips of the forceps to reach deeper and to reach the bulbar urethra, which is located deep in the pelvis. (clinical) [Ep 3 · 7:32](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=452)
- After the fistula is tied, a catheter is again inserted until it gently probes the tied fistula, allowing the surgeon to reconfirm that the residual fistula length is shorter than or equal to 5 millimeters. (clinical) [Ep 3 · 8:30](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=510)
- In the first 8 cases, initial measurements of the fistula from rectal to urethral orifice were 13, 15, 12, 10, 15, 21, 10, and 5 millimeters respectively. (clinical) [Ep 3 · 9:25](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=565)
- Seven of the first 8 cases required further dissection until the fistula was shorter than or equal to 5 millimeters, but case 8 did not require further dissection. (clinical) [Ep 3 · 9:39](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=579)
- During cystoscopy, normal saline refluxed into the pelvic floor through the fistula in 6 cases, indicating the fistula is large, but there was no reflux in 2 cases, indicating the fistula is very narrow. (clinical) [Ep 3 · 9:48](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=588)
- All 23 cases were well after mean follow-up of 2 years, with no evidence of diverticular formation owing to residual fistula on voiding cystourethrography or MRI. (clinical) [Ep 3 · 10:10](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=610)
- All dissections were uncomplicated and the postoperative courses were unremarkable. (clinical) [Ep 3 · 10:20](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=620)
- The residual fistula from rectal site to urethral site is much longer than expected. (clinical) [Ep 3 · 10:28](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=628)
- The new technique measuring the exact length of the fistula facilitates safe and complete excision of the fistula, reducing the risk of postoperative diverticulum formation due to incomplete fistula excision. (opinion) [Ep 3 · 10:37](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=637)
- For prostatic fistula dissection, if the laparoscopic surgeon has training for gallbladder removal or other fundamental techniques, they can perform the procedure. (opinion) [Ep 3 · 12:54](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=774)
- The key for dissection of the fistula is decompression of the bladder, which can be achieved with suprapubic catheter if the laparoscopic surgeon's technique is not yet proficient. (clinical) [Ep 3 · 13:31](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=811)
- For bulbar fistula dissection, the laparoscopic surgeon needs 5 to 10 cases of prostatic fistula experience before attempting bulbar cases. (opinion) [Ep 3 · 14:22](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=862)
- For bulbar fistula, the trocar position must be very close to the telescope, otherwise the tip of the instrument cannot reach the deep side of the pelvis or the bulbar fistula. (clinical) [Ep 3 · 14:43](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=883)
- If a sigmoid colostomy is made very proximal in the sigmoid or at the descending colon-sigmoid junction, there will be enough length to do a pull-through even for a high fistula. (clinical) [Ep 3 · 17:19](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1039)
- Laparoscopy can be used to help make the initial colostomy, allowing the surgeon to see exactly where they are. (clinical) [Ep 3 · 18:00](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1080)
- A left lower quadrant transverse incision can be made to pull out the sigmoid, figure out which end is which, and go proximal for colostomy creation. (clinical) [Ep 3 · 18:18](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1098)
- Transverse colostomy has too many problems including urine absorption, infection, and prolapse. (opinion) [Ep 3 · 18:37](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1117)
- With sigmoid colostomy, it is possible to place ports and work around the stoma without having to take it down for deep pelvic dissection. (clinical) [Ep 3 · 19:17](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1157)
- With ports placed closer to the umbilicus for bulbar fistulas, sigmoid colostomy location becomes even less of an issue. (opinion) [Ep 3 · 19:30](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1170)
- A sigmoid colostomy on the left side can be an obstacle for inserting trocars. (opinion) [Ep 3 · 19:57](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1197)
- For sigmoid colostomy, the surgeon can go in the left upper quadrant and go around lateral to the colostomy, so it is not an issue. (clinical) [Ep 3 · 20:11](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1211)
- For prostatic or bladder neck fistula, the dissection can be done without the measurement technique and still get very close to the end of the fistula. (opinion) [Ep 3 · 20:21](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1221)
- The laparoscopic approach for bulbar fistula is far more difficult and more dangerous, and the technique described is extremely complicated for the average pediatric surgeon. (opinion) [Ep 3 · 20:55](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1255)
- The PSARP technique is easy for bulbar fistula patients. (opinion) [Ep 3 · 21:10](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1270)
- There is no convincing data that the laparoscopic approach results in any better outcomes for bulbar fistulas than PSARP. (opinion) [Ep 3 · 21:20](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1280)
- The reason for using laparoscopic procedure even for bulbar fistula is to avoid cutting the anal sphincter and damaging the muscle and nerves for sphincters. (opinion) [Ep 3 · 21:32](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1292)
- If a good view of the fistula cannot be obtained on colostogram, the study should be repeated. (clinical) [Ep 3 · 22:32](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1352)
- Before operation, colonoscopy can be performed through the transverse colostomy if there is doubt whether the patient has a fistula. (clinical) [Ep 3 · 22:49](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1369)
- Combination of colonoscopy and cystoscopy can be done before operation if the colostogram does not show nice anatomy of the fistula. (clinical) [Ep 3 · 23:00](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1380)
- Combining VCUG and colostogram at the same time by putting dye in from both sides usually allows the fistula to be seen clearly. (clinical) [Ep 3 · 23:41](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1421)
- It is important to have an empty bladder when doing laparoscopic anorectal malformation repair. (clinical) [Ep 3 · 23:51](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1431)
- When a Foley catheter is placed at the beginning of the case, it can go into the fistula and rectum instead of the bladder, and this may not be discovered until the middle of the operation. (clinical) [Ep 3 · 24:04](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1444)
- It is a good idea to cystoscope all anorectal malformation patients at the beginning of the case to make sure the catheter is actually in the bladder before starting. (opinion) [Ep 3 · 24:22](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1462)
- When performing cystoscopy, saline must be injected, so bladder decompression via suprapubic tube cystostomy is needed; otherwise the bladder will be filled with saline and the pelvic floor cannot be seen. (clinical) [Ep 3 · 24:33](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1473)
- For bulbar fistula dissection, suprapubic tube cystostomy is needed to decompress the bladder, especially when performing cystoscopy. (clinical) [Ep 3 · 24:46](https://origin-library.globalcastmd.com/watch/imperforate-anus-rectourethral-fistula-technique-discussion-difficult-cases-1054?t=1486)
- There is no urgency to operate on an ARM patient on the day of birth as long as the abdomen is soft and not distended (clinical) [Ep 4 · 3:27](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=207)
- A flat bottom in a newborn with ARM usually indicates a high fistula and predicts poor continence (clinical) [Ep 4 · 11:01](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=661)
- Every ARM patient needs to be evaluated in context of three factors: type of malformation, quality of sacrum, and quality of spine (the 'ARM index') to predict continence (clinical) [Ep 4 · 11:47](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=707)
- A bladder neck fistula patient is very different from a perineal fistula patient in terms of continence prognosis (clinical) [Ep 4 · 12:47](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=767)
- About 95% of Down syndrome patients with ARM have no fistula (epidemiological) [Ep 4 · 7:04](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=424)
- Trans-scrotal fistulas are generally low-type malformations in more than 90% of cases, suitable for primary neonatal repair — Ivo (clinical) [Ep 4 · 30:31](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=1831)
- The critical cutoff point for timing of ARM repair is when infants transition from breast milk/formula to solid food (around 6 months), as stool character changes and rectal dilation begins — Jack (clinical) [Ep 4 · 26:26](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=1586)
- In newborn male perineal fistula repair, the urethra is incredibly close to the rectum, and circumferential anterior mobilization risks urethral injury — Jack (clinical) [Ep 4 · 35:08](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=2108)
- A cutback technique (extending rectum posteriorly without anterior dissection) in males avoids dangerous anterior dissection and reduces stricture, and does not require daily dilation postoperatively — Jack (clinical) [Ep 4 · 41:01](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=2461)
- If anal opening is left outside the sphincter mechanism, patients may have anterior leakage during athletics or with loose stool when they try to close the sphincter (clinical) [Ep 4 · 42:04](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=2524)
- An anus is defined as a properly sized hole in the center of the sphincter that is mucosa-lined (clinical) [Ep 4 · 28:08](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=1688)
- Perineal fistula is distinguished from vestibular fistula by presence of perineal body; vestibular fistula has no perineal body — Jack (clinical) [Ep 4 · 57:24](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=3444)
- What looks like a very small perineal body in a newborn female actually gets much bigger as the child grows (clinical) [Ep 4 · 49:54](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=2994)
- From a gynecological standpoint, building as good a perineal body as possible is important for separation of reproductive organs from GI tract, sexual functioning, and possibility of vaginal delivery — Jonathan (clinical) [Ep 4 · 50:49](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=3049)
- Women can become incontinent from vaginal delivery even without ARM history, so the risk after ARM repair is too high to recommend vaginal delivery — Paola (opinion) [Ep 4 · 52:52](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=3172)
- Vaginal delivery after ARM repair is possible with lateral episiotomy if needed and proper planning with a pediatric gynecologist familiar with ARM repairs (opinion) [Ep 4 · 53:29](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=3209)
- Cutback technique preserves more rectal tissue including potential sensory fibers at the dentate line — Paola (clinical) [Ep 4 · 71:19](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=4279)
- Cloaca (single perineal opening with no anus) does not require endocrine evaluation and electrolytes will be normal, unlike urogenital sinus with normal anus which may indicate congenital adrenal hyperplasia (clinical) [Ep 4 · 55:50](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=3350)
- The incidence of congenital adrenal hyperplasia in the ARM population is almost zero — Jonathan (epidemiological) [Ep 4 · 56:49](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=3409)
- All ARM patients need esophageal atresia ruled out before proceeding with colostomy (clinical) [Ep 4 · 83:01](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=4981)
- If normal physical exam, normal chest x-ray, and normal ECG, significant cardiac problems that would interfere with anesthesia are never found in ARM patients — Jack (clinical) [Ep 4 · 93:06](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=5586)
- Every ARM patient with anal stenosis must have presacral mass ruled out with plain x-ray of sacrum and ultrasound looking specifically at presacral space (clinical) [Ep 4 · 75:58](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=4558)
- Spinal ultrasound can detect presacral masses if the radiologist is specifically looking for them and increases depth of examination, though very small masses may be missed — Jonathan (clinical) [Ep 4 · 69:21](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=4161)
- Missing a presacral mass can result in teratoma becoming malignant; at least two cases are known where presacral mass was missed on newborn evaluation (clinical) [Ep 4 · 70:57](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=4257)
- Cross-table lateral films showing very short distance between skin and rectum are most useful; long distances may be falsely elevated due to meconium preventing air from reaching the rectum — Jack (clinical) [Ep 4 · 93:40](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=5620)
- The 'Twitter sign' (air visible in fistula tract on cross-table lateral) is consistent with high rectum with probable rectourethral fistula (clinical) [Ep 4 · 91:51](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=5511)
- It is exceedingly rare to have perineal meconium and a long fistula; almost uniformly these patients have very reachable rectum suitable for primary repair (clinical) [Ep 4 · 92:38](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=5558)
- Colostomy should be opened at the very proximal sigmoid (where sigmoid begins at left retroperitoneal attachments) so that part of colon won't prolapse (clinical) [Ep 4 · 97:28](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=5848)
- Complete evacuation of distal meconium at time of colostomy is a very important job that should not be neglected (clinical) [Ep 4 · 98:53](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=5933)
- Laparoscopic colostomy allows precise identification of proximal sigmoid and creation of stomas without skin bridge, avoiding wound complications — Jonathan (clinical) [Ep 4 · 98:53](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=5933)
- What affects UTI rate in ARM patients with colostomy is presence of vesicoureteral reflux or neurogenic bladder, not stoma type — Jonathan (clinical) [Ep 4 · 101:15](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=6075)
- Loop stomas may be acceptable when fistula is very small or bladder is normal with no other problems, and especially if repair is done early (within 3 months) — Jonathan (opinion) [Ep 4 · 102:35](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=6155)
- Opening colostomy too distal leaves insufficient bowel for the pull-through procedure (clinical) [Ep 4 · 103:32](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=6212)
- Perineal ultrasound for determining rectal position requires a skilled radiologist who does not push too hard and a quiet baby who is not valsalving — Ivo (clinical) [Ep 4 · 31:09](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=1869)
- Dissection of the fistula in anorectal malformations must extend to the 'red line' (urethral level) to prevent residual fistula, while avoiding injury to nerves, prostate, urethra, and sphincters. (clinical) [Ep 2 · 0:21](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=21)
- A novel technique allows the surgeon to measure the inside length of the rectourethral fistula between the rectal opening and urethral orifice using a calibrated catheter inserted laparoscopically while another surgeon observes its emergence via cystoscopy. (clinical) [Ep 2 · 2:37](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=157)
- If the residual fistula length is longer than 5 millimeters, the rectal end is further dissected toward the urethra using mucosectomy to prevent injury to the prostate and urethra. (clinical) [Ep 2 · 4:27](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=267)
- For bulbar fistula repair, suprapubic tube cystostomy is very important to decompress the bladder and open up a clear view of the deep pelvic floor; otherwise the operation cannot be performed. (clinical) [Ep 2 · 6:16](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=376)
- For bulbar fistula, trocar position differs from prostatic fistula in that right and left trocars are placed much closer to the telescope, which is key for reaching the deep pelvis despite increased difficulty in forceps handling. (clinical) [Ep 2 · 6:49](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=409)
- In a series of 23 males with rectourethral fistulas, initial measurements showed fistula lengths of 13, 15, 12, 10, 15, 21, 10, and 5 millimeters from rectal to urethral orifice; seven cases required further dissection to achieve ≤5mm residual length. (clinical) [Ep 2 · 9:25](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=565)
- During cystoscopy, normal saline refluxed into the pelvic floor through the fistula in 6 of 8 cases, indicating a large fistula; no reflux occurred in 2 cases, indicating a very narrow fistula. (clinical) [Ep 2 · 9:48](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=588)
- All 23 cases were well after mean follow-up of 2 years with no evidence of diverticular formation due to residual fistula on voiding cystourethrography or MRI. (clinical) [Ep 2 · 10:10](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=610)
- The residual fistula from rectal site to urethral side was much longer than expected. (clinical) [Ep 2 · 10:28](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=628)
- Sigmoid colostomy can fix the rectum and colon, requiring takedown of the sigmoid colostomy to achieve adequate length for pull-through, which is why right transverse colostomy is preferred. (opinion) [Ep 2 · 16:24](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=984)
- A sigmoid colostomy placed very proximal in the sigmoid or at the descending colon-sigmoid junction provides enough length for pull-through even for high fistulas. (clinical) [Ep 2 · 17:19](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1039)
- Transverse colostomy has too many problems including urine absorption, infection, and prolapse; a very small minority of surgeons still use transverse colostomies. — Sherif Emil (opinion) [Ep 2 · 18:37](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1117)
- With sigmoid colostomy on the left side, ports can be placed in the left upper quadrant lateral to the colostomy without difficulty. (clinical) [Ep 2 · 19:57](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1197)
- For prostatic or bladder neck fistula, the dissection can be done without the measurement technique if the surgeon is familiar with laparoscopic anorectal malformation operations and can get very close to the end of the fistula. (opinion) [Ep 2 · 20:21](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1221)
- The laparoscopic approach for bulbar fistula is far more difficult and more dangerous than for higher fistulas; the technique is extremely complicated for the average pediatric surgeon, and the PSARP technique is easy for those patients. (opinion) [Ep 2 · 20:55](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1255)
- There is no convincing data that the laparoscopic approach results in any better outcomes for bulbar fistulas than PSARP does. (opinion) [Ep 2 · 21:20](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1280)
- The reason for using laparoscopy even for bulbar fistula is to avoid cutting the anal sphincter muscle and nerves. (opinion) [Ep 2 · 21:32](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1292)
- Combining VCUG and distal colostogram by putting dye in from both sides usually allows clear visualization of the fistula. (clinical) [Ep 2 · 23:41](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1421)
- It is probably a good idea to cystoscope all anorectal malformation cases at the beginning to ensure the catheter is in the bladder before starting the case. (opinion) [Ep 2 · 24:22](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1462)
- When performing cystoscopy during the case, saline injection fills the bladder, so suprapubic tube cystostomy is needed to decompress the bladder; otherwise the pelvic floor cannot be visualized. (clinical) [Ep 2 · 24:33](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1473)
- In thoracoscopic TEF repair, the majority of surgeons divide the distal esophagus completely, but leaving one-quarter of the fistula uncut prevents cranial retraction of the distal esophagus and makes anastomosis easier. (clinical) [Ep 2 · 28:04](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1684)
- For the proximal esophagus in TEF repair, leaving 10-15% of the tip uncut as a 'cap' allows grasping with forceps without damaging the anastomotic site. (clinical) [Ep 2 · 29:09](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1749)
- If there is a 1-2 vertebral body gap in esophageal atresia, the assistant can pull the proximal esophagus caudally using the uncut cap of the proximal esophagus. (clinical) [Ep 2 · 29:43](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1783)
- In thoracoscopic TEF repair, the first stitch is placed in the middle of the posterior wall rather than at the edge, which is much easier. (clinical) [Ep 2 · 30:42](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1842)
- The fistula is completely divided after 1-2 anastomotic stitches are placed, and the uncut cap of the proximal esophagus is divided after 2-3 stitches. (clinical) [Ep 2 · 34:44](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=2084)
- Clips for TEF closure should be applied to oppose rather than crush tightly; tight clipping will crush the esophageal muscle and cause erosion, leading to fistula recurrence. (clinical) [Ep 2 · 44:18](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=2658)
- Finding the fistula laparoscopically in esophageal atresia is much easier than open; you can appreciate how much esophagus to leave without leaving too much on the trachea side. (opinion) [Ep 2 · 41:28](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=2488)
- Dissecting the upper segment of the esophagus thoracoscopically is difficult; the main challenge is handling the esophagus without damaging the wall needed for anastomosis. (opinion) [Ep 2 · 41:48](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=2508)
- In thoracoscopic TEF repair, the first half of the case (dissection and fistula division) feels advantageous, but once starting the anastomosis, the surgeon questions why they chose the thoracoscopic approach. — Sherif Emil (opinion) [Ep 2 · 42:36](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=2556)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Rollins' data showed approximately 30% of perineal fistula patients had associated anomalies across GU and cardiac systems — Jonathan summarizing the discussion [Ep 4 · 87:33](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=5253)
- Loop stomas theoretically allow distal spillage and have high prolapse rates, but recent data from Toronto shows no difference in UTI rates between loop and divided stomas — Jonathan summarizing the discussion [Ep 4 · 101:15](https://origin-library.globalcastmd.com/watch/arms-in-neonates-pediatric-colorectal-controversies-2014-1100?t=6075)
- An empty bladder is critically important when doing laparoscopic anorectal malformation repair; sometimes the Foley catheter goes into the fistula and rectum rather than the bladder, which may not be discovered until mid-operation. — The host summarizing the discussion [Ep 2 · 23:51](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=1431)
- Steve Rothenberg uses clips routinely for TEF and has never had a clip erode, despite other surgeons experiencing clip erosion into the esophagus with fistula recurrence. — The host summarizing the discussion [Ep 2 · 43:19](https://origin-library.globalcastmd.com/watch/tricks-imperforate-anus-and-rectourethral-fistula-631?t=2599)

## Changelog
- Sep 9: 1 item no longer name rectourethral fistula
- Sep 8: 2 items no longer name rectourethral fistula
- Sep 7: 7 items added automatically

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