# 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 · 53 cited statements

## Episodes
### Surgical Management
- [Update Course Rewind: Perineal Body Sparing PSARP 2023](https://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857) — video · 2:55 · [machine version](https://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://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899) — video · 30:29 · [machine version](https://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://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095) — video · 88:20 · [machine version](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095.md)

## Chapters
- [0:00](https://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://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://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://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://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://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://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://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://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://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://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=0) Introduction and Case Presentation (Ep 2)
- [0:45](https://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://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=120) Benefits and Summary (Ep 2)
- [2:35](https://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=155) Closing (Ep 2)
- [0:00](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=0) Introduction and Case 1: Timing of PSARP for Vestibular Fistula (Ep 3)
- [9:07](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=547) Perineal Body-Preserving PSARP Technique (Ep 3)
- [15:49](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=949) Postoperative Anal Dilations Controversy (Ep 3)
- [19:30](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1170) Case 2: Timing of Hirschsprung Pull-Through (Ep 3)
- [24:27](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1467) Botulinum Toxin Use in Hirschsprung Disease (Ep 3)
- [26:35](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1595) Case 3: Hirschsprung Disease and Anorectal Malformations (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- "Two studies in 2021 found no difference in wound complications, re-operations, or readmissions between early (less than 7-14 days) and delayed (6 weeks to 8 months) PSARP for vestibular fistulas" — Jamie Harris (clinical) [Ep 3 · 5:14](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=314)
- "Wound breakdown and dehiscence was the most common complication in both neonatal and delayed PSARP groups, occurring in approximately 5-6% with no significant difference between groups" — Jamie Harris (clinical) [Ep 3 · 6:00](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=360)
- "For vestibular fistula dilations, recommend only dilating to 7 Hegar to decrease potential scarring along the tract for future PSARP" — Jamie Harris (clinical) [Ep 3 · 2:33](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=153)
- "Perineal body-preserving PSARP showed no dehiscence, no prolapse, and only 13% required revision of anal stenosis at one-year follow-up in 2023 publication" (clinical) [Ep 3 · 10:22](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=622)
- "Two-thirds of patients undergoing perineal body-preserving PSARP went home on postoperative day one" (clinical) [Ep 3 · 10:36](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=636)
- "Perineal body-preserving PSARP does not add operative time compared to standard PSARP" — Jamie Harris (clinical) [Ep 3 · 14:03](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=843)
- "Anal dilations are associated with parental anxiety, PTSD for both patients and caregivers, and post-traumatic stress symptoms in families" (clinical) [Ep 3 · 16:31](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=991)
- "Preoperative dilations appear to be more tolerated than postoperative dilations" (opinion) [Ep 3 · 17:00](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1020)
- "In Spanish study, children adequately sized at initial post-PSARP appointment did not receive dilations, while undersized children received dilations" (clinical) [Ep 3 · 17:19](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1039)
- "Single institution review showed 2 children in each group (dilations vs no dilations) required re-operation for neoanal stricture, and approximately 15% required Heineke-Mikulicz stricturoplasty" (clinical) [Ep 3 · 18:01](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1081)
- "PCPLC retrospective study of Hirschsprung disease found 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 (clinical) [Ep 3 · 20:25](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1225)
- "Multi-center retrospective study found 24% of Hirschsprung patients received at least one Botox injection" — Nelson Rosen (epidemiological) [Ep 3 · 23:40](https://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 receiving Botox (30% vs 50%)" — Nelson Rosen (clinical) [Ep 3 · 23:58](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1438)
- "Patients receiving Botox at time of pull-through had higher risk of diaper rash (60%)" — Nelson Rosen (clinical) [Ep 3 · 24:23](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1463)
- "Early work from Boston used per-kilogram Botox dosing up to maximum of 100 units" — Nelson Rosen (clinical) [Ep 3 · 24:58](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1498)
- "Rate of concurrent Hirschsprung disease and anorectal malformation is approximately 2% based on Pena's series" (epidemiological) [Ep 3 · 27:03](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1623)
- "Some papers show rate of concurrent Hirschsprung and ARM as high as 3-4%, while recent paper showed less than 1%" (epidemiological) [Ep 3 · 27:14](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1634)
- "Single center study found ganglion cells in 90% of rectal fistula specimens taken during PSARP, with hypoganglionosis or absent ganglion cells in the rest" (clinical) [Ep 3 · 27:39](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1659)
- "Patients with both Hirschsprung disease and anorectal malformation tend to have chromosomal anomalies, particularly trisomy 21" (clinical) [Ep 3 · 28:24](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1704)
- "Fistula dilations represent controlled tears when starting from pinhole size, not true stretching" — Nelson Rosen (clinical) [Ep 3 · 8:41](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=521)
- "Goal of fistula dilation is to maintain patency just large enough for soft, mustardy stool to pass through" — Nelson Rosen (clinical) [Ep 3 · 4:17](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=257)
- "Perineal body-preserving PSARP is essentially the same technique used for bulbar fistula applied to vestibular fistula" — Nelson Rosen (clinical) [Ep 3 · 11:04](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=664)
- "Key technical principle for perineal body-preserving PSARP is to mobilize lateral planes and back wall thoroughly before coming around the anterior common plane" — Nelson Rosen (clinical) [Ep 3 · 11:32](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=692)
- "Perineal body-preserving PSARP can be converted to standard PSARP by extending the incision if visualization is inadequate" — Jamie Harris (clinical) [Ep 3 · 13:09](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=789)
- "Families competent with irrigations will start treatment for enterocolitis before calling the surgeon" (opinion) [Ep 3 · 21:36](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1296)
- "Patients with longer aganglionic segments who cannot be adequately decompressed at home may require earlier pull-through to prevent enterocolitis or perforation" (clinical) [Ep 3 · 22:07](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1327)
- "Some data suggests possibly better continence in delayed Hirschsprung pull-through group, but studies have been underpowered" (clinical) [Ep 3 · 22:39](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1359)
- "Ultrasound guidance for Botox injection allows visualization of needle placement, internal and external anal sphincter layers, superficial external anal sphincter, and sometimes puborectalis" (clinical) [Ep 3 · 25:48](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1548)
- "Absence of ganglion cells in fistula tissue does not necessarily mean Hirschsprung disease, as fistula tissue is not physiologic tissue" (clinical) [Ep 3 · 27:54](https://library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-colorectal-debunking-dogma-10899?t=1674)
- "In absent vagina situations with recto-vestibular fistula, the urethra is characteristically enlarged" — Marc Levitt (clinical) [Ep 1 · 19:47](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=1187)
- "Total body prep from nipples to toes is standard for these patients, allowing flexibility to flip between supine and prone positions" — Todd Ponsky (host_summary) [Ep 1 · 2:10](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=130)
- "In babies this small, MRI has difficulty delineating uterine and ovarian structures" — Marc Levitt (clinical) [Ep 1 · 3:21](https://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://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://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://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://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://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://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://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://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://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://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://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=4177)
- "MRI has limited ability to determine presence of vaginal lumen in very young patients unless there is clear hematocolpos or hydrocolpos" — Marc Levitt (host_summary) [Ep 1 · 82:15](https://library.globalcastmd.com/watch/posterior-sagittal-anorectaplasty-in-a-female-pediatric-colorectal-1095?t=4935)
- "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://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://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://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://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://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://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=68)
- "One study has 6 patients and the other has 4 patients." — Em Gootee (host_summary) [Ep 2 · 1:17](https://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=77)
- "The techniques are similar but slightly different." — Em Gootee (host_summary) [Ep 2 · 1:20](https://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=80)
- "The Boston technique involves a slight posterior sagittal extension of the incision." — Steven Lee (clinical) [Ep 2 · 1:26](https://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://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://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://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://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=120)
- "Perineal body sparing techniques can reduce post-operative infection risks in patients undergoing dilations." — Em Gootee (host_summary) [Ep 2 · 2:12](https://library.globalcastmd.com/watch/update-course-rewind-perineal-body-sparing-psarp-2023-7857?t=132)

## Changelog
- Sep 11: 3 items added automatically

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