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Imperforate Anus & Rectourethral Fistula Technique & Discussion: Difficult Cases
Chapter 1 of 5 · Fundamentals
Measurement technique
Introduction and Fistula Measurement Technique Overview
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
All dissections were uncomplicated and the postoperative courses were unremarkable.
The residual fistula from rectal site to urethral site is much longer than expected.
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.
For prostatic fistula dissection, if the laparoscopic surgeon has training for gallbladder removal or other fundamental techniques, they can perform the procedure.
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.
For bulbar fistula dissection, the laparoscopic surgeon needs 5 to 10 cases of prostatic fistula experience before attempting bulbar cases.
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.
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.
Laparoscopy can be used to help make the initial colostomy, allowing the surgeon to see exactly where they are.
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.
Transverse colostomy has too many problems including urine absorption, infection, and prolapse.
With sigmoid colostomy, it is possible to place ports and work around the stoma without having to take it down for deep pelvic dissection.
With ports placed closer to the umbilicus for bulbar fistulas, sigmoid colostomy location becomes even less of an issue.
A sigmoid colostomy on the left side can be an obstacle for inserting trocars.
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.
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.
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.
The PSARP technique is easy for bulbar fistula patients.
There is no convincing data that the laparoscopic approach results in any better outcomes for bulbar fistulas than PSARP.
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.
If a good view of the fistula cannot be obtained on colostogram, the study should be repeated.
Before operation, colonoscopy can be performed through the transverse colostomy if there is doubt whether the patient has a fistula.
Combination of colonoscopy and cystoscopy can be done before operation if the colostogram does not show nice anatomy of the fistula.
Combining VCUG and colostogram at the same time by putting dye in from both sides usually allows the fistula to be seen clearly.
It is important to have an empty bladder when doing laparoscopic anorectal malformation repair.
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.
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.
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.
For bulbar fistula dissection, suprapubic tube cystostomy is needed to decompress the bladder, especially when performing cystoscopy.