Posterior sagittal anorectoplasty for the surgical treatment of rectourethral fistula

  • Abstract
    Approximately seventy percent of all male patients born with an anorectal malformation suffer from a rectourethral fistula. This is an abnormal communication between rectum and urethra. The goal of the surgeon is to separate the rectum from the urinary tract, to close the urethral fistula, to pull down the rectum, and to place it precisely within the limits of the sphincter mechanism. The procedure we demonstrate here is called a Posterior Sagittal Anorectoplasty (PSARP).
  • 00'29" Background
    Approximately seventy percent of all male patients born with an anorectal malformation suffer from a rectourethral fistula. That is an abnormal communication between rectum and urethra. When the communication is located at the lowest portion of the posterior urethra, it is called rectourethral bulbar fistula. When it is located higher in the posterior urethra, it is called rectourethral prostatic fistula. The goal of the operation is to separate the rectum from the urinary tract, to close the urethral fistula, to pull down the rectum, and to place it precisely within the limits of the sphincter mechanism.
  • 01'17" Sphincter identification
    Here, I’m showing the perineum of a patient born with a rectourethral fistula. The center of the sphincter is clearly demonstrated by the use of an electrical stimulator.
  • 01'30" Midline incision
    Only the tip of the needle should touch the tissues with quick movements to avoid excessive tissue burning. The incision is located exactly in the midline in between both buttocks running from the middle portion of the sacrum and through the center of the sphincter. A sharp Weitlaner retractor is used, placing it rather superficially in the wound. The coccyx is divided in the midline when I feel that more exposure is required. The entire sphincter mechanism is divided until the perineal fat is identified, as shown here. These are the parasagittal fibers. The muscle complex can now be seen very clearly running perpendicularly to the parasagittal fibers. Same structures on the opposite side. The levator muscle is also divided in the midline. Deeper to the levator muscle, one can identify a very clear, white structure which is a very important surgical landmark; it is actually a fascia located behind the rectum.
  • 02'57" Dissecting the rectal wall
    When dealing with a bulbar-urethral fistula like shown in this diagram, the rectum is found just deeper to the levator, and it is very safe to open the rectum in between two silk stitches taking the rectal wall. This diagram shows an exposed rectourethral bulbar fistula. Back to our case: we knew that we were dealing with a recto-urethral bulbar fistula, and therefore, I was confident to place two silk stitches taking the fascia and the posterior rectal wall. The rectum is then opened in between both stitches.
  • 03'38" Placement of sutures
    As we progress in the midline opening of the posterior rectal wall, fine silk sutures are placed taking the edge of the rectal wall, which provides an excellent exposure of the rectal lumen. The opening continues with a special emphasis in staying in the midline, which will take us exactly to the fistula orifice. The fistula is shown here with a lacrimal probe. A last silk stitch is placed, taking the edge of the fistula. This last stitch will eventually help us to locate the fistula site after the rectum is separated from the urethra.
  • 04'39" Separating rectum from urethra
    The next surgical step represents the most delicate part of the operation, which is the separation of the rectum from the urethra. For this, multiple 6/0 silk sutures are placed, one or two millimeters apart, positioned in a semi-circumferential fashion, surrounding the upper part of the fistula. These stitches will prove to be extremely useful, because they will represent a very good handle to apply uniform traction on the anterior rectal wall to facilitate its separation from the posterior urethra. The stitches should only take the rectal mucosa. This diagram shows the cutting of the rectal mucosa in between the fistula and our stitches. And here we can see the same maneuver in our patient. No attempt should be made to continue the separation of rectum from the urethra at this point. A very helpful and valuable maneuver at this point is to expose the lateral wall of the rectum and dissect the rectum between the rectal fascia and the rectal wall. This is a very clear plane. The dissection of the rectum should only be performed while staying as close as possible to the rectal wall but without injuring the wall itself. Having established the lateral plane of dissection, we can now come back to the separation of rectum from urethra, having as a reference the lateral wall of the rectum. Same dissection is initiated in the opposite side. Again, in this side, once the lateral plane has been clearly established, we can come back to the separation of rectum and urethra. The dissection proceeds slowly and meticulously, checking the thickness of the rectal wall as we progress with the dissection. The pre-established lateral plane of dissection is always a point of reference as shown here. The dissection continues until the rectum has been completely separated from the urethra, as shown in this diagram. This is the fistula, and this, the rectum completely separated. The rectum has been separated completely from the urinary tract in our patient.
  • 08'28" Dissection of rectal wall
    The next step is to dissect the rectum to gain enough length to reach the perineum without tension.
  • 08'38" Suturing of urethral fistula
    The urethral fistula is then sutured with a few 6/0 long-term absorbable sutures.
  • 09'02" Identifying limits of sphincter
    The next step is to identify the limits of the sphincter and to mark them with silk sutures. Posterior limit. Anterior limit.
  • 09'20" Perineal reconstruction
    At this point, we must evaluate the available space as compared with the size of the rectum. In this particular case, the rectum seems to fit well into the available space. The perineal body is reconstructed, bringing together the anterior edge of the muscle complex as shown in this illustration. These sutures bring together the anterior limits of the sphincter. Here we can see the real suturing of the levator muscle. The rectum is passed in front, and the sutures are tied. Long-term absorbable sutures are placed and laid down taking the posterior edge of the muscle complex. These stitches include an anchoring bite of the posterior rectal wall. The last stitch brings together the posterior limits of the sphincter. Distal rectal fossa and parasagittal fibers are sutured in the midline. The rectum is now located within the limits of the sphincter mechanism.
  • 12'18" Anoplasty
    The anoplasty is performed. The first two stitches include the posterior and anterior corners of the new anus. These stitches are anchored to the sterile towels. Redundant or damaged rectal tissue is trimmed off. And the first lateral stitch is placed taking the skin edge and the full-thickness rectal wall. The same maneuver is repeated on the opposite side. Followed by intermediate 6-0 long-term absorbable sutures, for a total of 16 circumferential sutures. All these stitches are tied under some tension, which will help to invert the muscosa and to avoid prolapse.
  • Related medias
    Approximately seventy percent of all male patients born with an anorectal malformation suffer from a rectourethral fistula. This is an abnormal communication between rectum and urethra. The goal of the surgeon is to separate the rectum from the urinary tract, to close the urethral fistula, to pull down the rectum, and to place it precisely within the limits of the sphincter mechanism. The procedure we demonstrate here is called a Posterior Sagittal Anorectoplasty (PSARP).