Colorectal Quiz Episode 2: When to redo a PSARP

Published: 2021-01-25

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Rod Girardo — host
Mark Levitt — guest
Todd Ponsky — guest
Speaker 4

Chapters

0:00Introduction and Clinical Challenge — Introduction to the difficulty of deciding when to reoperate after anorectoplasty, with emphasis that the first operation may be the only chance for good outcomes.
3:19Case 1: Seven-Year-Old Male — Presentation of a seven-year-old boy with rectal prolapse and posteriorly mislocated anus after repair of prostatic fistula, with tethered cord and sacral ratio 0.66. Discussion of prognostic factors including malformation type, sacral ratio, and spine innervation.
8:15Case 2: Four-Year-Old Female and Technical Pearls — Presentation of a four-year-old female with posteriorly located anoplasty after vestibular fistula repair, with normal spine and excellent sacrum. Discussion of visual cues for proper anus placement and use of electrical stimulator.
11:00JPS Study Review and Redo Outcomes — Review of Journal of Pediatric Surgery article on redo operations showing improved quality of life, 20% continence achievement in poor-prognosis patients, and excellent outcomes in good-prognosis patients. Discussion of optimal timing for redo surgery.
16:02Summary and Conclusion — Summary emphasizing that redo surgery can improve continence regardless of original prognosis group and importantly improves quality of life.

Key claims

0:00If you don't get anorectoplasty perfect, you might not have the best outcomes, which separates it from other surgical procedures — Rod Girardo
0:50A lot of surgeons agree that oftentimes your first shot might be your only shot to give this patient a good outcome and the right anatomy — Rod Girardo
4:30The original malformation was a prostatic fistula and the patient has a tethered cord and a sacral ratio of 0.66 — Mark Levitt
5:50The family doesn't really care how technically elegant is your anaplasty. What they care about is whether that anaplasty that you make is going to work — Rod Girardo
6:15The higher the malformation is, the worse the prognosis — Rod Girardo
6:30Sacrum ratio 0.7 or greater usually means normal or close to normal sphincters and good muscle tone and spine innervation — Rod Girardo
6:55The most common associated spinal anomaly is tethered cord, but the worst is myelomeningocele — Rod Girardo
6:55Patients with myelomeningocele have much more trouble with continence — Rod Girardo
7:44It's amazingly common to have a mislocated anus — Rod Girardo
7:55A key pitfall is opening the PSARP incision first; you should mark the sphincters first, then open the PSARP so you don't get confused when placing the anoplasty — Rod Girardo
8:40The patient was born with a vestibular fistula, the spine is normal and has an excellent sacrum, so this is a much better prognosis bowel control patient — Mark Levitt
9:50The stimulator is the same electrical stimulator that anesthesia uses for their train of four — Mark Levitt
10:05You have to tell your anesthesiologist not to give skeletal muscle relaxant because the stimulator is a little bit weaker than the traditional stimulator — Mark Levitt
10:40In higher malformations like bladder neck fistula in a boy, the sphincter complex isn't always where you think it's going to be; sometimes those sphincter complexes are more anterior than anticipated — Rod Girardo
12:00The vast majority of redo operations were for mislocation, then came stricture, and less common reasons included remnant of original fistula (roof), rectal prolapse, and others — Mark Levitt
12:30Quality of life improved with a redo operation — Mark Levitt
12:40Patients had an improved ability to achieve continence after redo — Mark Levitt
12:5020% of patients with a poor sacrum or poor spine actually developed bowel control after their redo — Mark Levitt
13:05Patients with good potential—a good sacrum and good spine—did extremely well after redo — Mark Levitt
13:15Patients who did not develop voluntary bowel movements were still able to be clean with a bowel management program with enemas or antegrade using a Malone — Mark Levitt
13:21The average age of patients in the study is about three and a half years — Mark Levitt
13:28If you know the anatomy is off, you should do the redo — Mark Levitt
13:40There's an advantage to getting the anatomy right the younger the child is — Mark Levitt
14:10Many patients present after the age of potty training because they're incontinent, and evaluation reveals the reason is they don't have the best operation — Mark Levitt
14:30When doing redo at older age, usually add a Malone at the same time so patients can learn how to get control with their new anatomy before trying voluntary bowel movements — Mark Levitt
14:43The process of learning control with new anatomy after redo may take 6 to 12 months — Mark Levitt

Cases discussed

3:19Seven-year-old male with rectal prolapse and posteriorly mislocated anus after repair of anorectal malformation
8:15Four-year-old female with posteriorly located anoplasty after vestibular fistula repair

Points of disagreement

14:43Timing of redo surgery for borderline mislocated anus (50% within sphincter complex)
- Mark Levitt: Would probably redo them and do a Malone, get them perfectly clean mechanically, then see if they can develop bowel control
- Rod Girardo: Might be more conservative and let the child take their car out for a ride first, see how it works; if it drives well, stay with that car; if not, then consider redo

Open questions

What is the right age to make decisions about redo surgery?
For a patient with 50% of anus within sphincter complex at age 3.5 years with incontinence, should you redo immediately or wait to see if they develop continence?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Redo PSARP: From Last Resort to Strategic Intervention

How thinking and practice on this topic have changed over time, as told in this episode. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · How the thinking changed · AI-written, human-reviewed

The Old Reluctance

For years, reoperation after posterior sagittal anorectoplasty carried the weight of failure — a tacit admission that the first operation, which many believed represented the only real chance at continence, had not delivered 0:00 0:50. The prevailing logic held that scarring from the initial dissection would compromise whatever functional potential remained, and that subjecting a child to a second major pelvic operation risked making things worse. Redo surgery was reserved for the most egregious technical errors or intolerable symptoms like recurrent prolapse. The threshold for intervention was high, and many children with suboptimal anatomy were managed medically — laxatives for those with posterior mislocation, bowel management programs for those who could not achieve continence — rather than returned to the operating room.

This conservatism was not irrational. The anatomy is unforgiving, the margin for error narrow, and the consequences of a poorly executed anorectoplasty are lifelong. Without clear evidence that redo operations improved outcomes, the default was to avoid them.

What Shifted

The change came from accumulated experience at centers performing redo operations and, critically, from systematic review of those outcomes. A study published in the *Journal of Pediatric Surgery* examined patients who underwent redo PSARP and found that quality of life improved after reoperation 12:30. More striking: 20% of patients with poor prognostic factors — abnormal sacrum or spine — achieved voluntary bowel control after redo, and those with good anatomy did extremely well 12:50 13:05. Even patients who did not develop voluntary bowel movements were able to maintain cleanliness with bowel management programs, often more effectively than before the redo 13:15.

The most common indication for reoperation was mislocation of the anus, followed by stricture and less common issues like residual fistula or prolapse 12:00. The average age at redo in the study was three and a half years 13:21, but the discussants noted that many patients presented later, after failed toilet training, when incontinence prompted reevaluation and the discovery of suboptimal anatomy 14:10.

Two technical insights also emerged. First, the electrical stimulator — the same device anesthesia uses for train-of-four monitoring — became standard for intraoperative sphincter mapping, though it requires that no skeletal muscle relaxant be given because the stimulator is weaker than traditional nerve stimulators 9:50 10:05. Second, the sequence of dissection matters: marking the sphincter complex before opening the original PSARP incision prevents confusion about where the anus should sit 7:55. In higher malformations like bladder neck fistula, the sphincter complex may lie more anterior than expected, making visual and functional cues essential 10:40.

Current Practice

The discussants now advocate early redo when anatomy is clearly wrong 13:28. There is an advantage to correcting mislocation while the child is still in diapers, allowing them to live with proper anatomy for a year or two before toilet training begins 13:40. For older children presenting after failed toilet training, redo is often combined with a Malone appendicostomy so they can achieve cleanliness with antegrade enemas while learning to use their new anatomy — a process that may take six to twelve months 14:30 14:43.

Prognostic factors remain central to decision-making. Higher malformations carry worse prognosis 6:15. A sacral ratio of 0.7 or greater suggests normal or near-normal sphincters and intact innervation 6:30. Tethered cord is the most common associated spinal anomaly, but myelomeningocele is the worst for continence outcomes 6:55 6:55. The original malformation type, sacral quality, and spine integrity together determine what is realistic to expect from reoperation 4:30 8:40.

What Remains Unsettled

The threshold question persists: when is anatomy "good enough" to avoid reoperation? One discussant posed the case of a three-and-a-half-year-old with an anus 50% within the sphincter complex — half in, half out — and complete incontinence. No clear answer emerged. The decision remains individualized, balancing the child's age, the degree of mislocation, the family's tolerance for another operation, and the surgeon's judgment about whether the current anatomy can ever function.

Timing is also debated. Early redo avoids the psychological burden of failed toilet training, but some families prefer to wait and see if the child can compensate. Late redo allows for a more definitive assessment of function but may require concurrent bowel management procedures.

Finally, the question of how much improvement is enough. Quality of life gains are real 12:30, but whether a 20% chance of continence in poor-prognosis patients justifies reoperation depends on what the alternative looks like — and that calculation is different for every family.

Takeaways from this story

20% of poor-prognosis patients achieve continence after redo; those with good sacrum/spine do extremely well.
Mark sphincters before opening the PSARP incision to avoid mislocation during closure.
In bladder neck fistula, sphincter complex may lie more anterior than expected — use stimulator and visual cues.
Older children undergoing redo often need concurrent Malone; learning new anatomy takes 6-12 months.

Topic overview

A discussion of when to perform revision posterior sagittal anorectoplasty (PSARP) in children with anorectal malformations who have persistent fecal incontinence after initial repair. The speakers present two cases—a seven-year-old male with rectal prolapse and posteriorly mislocated anus, and a four-year-old female with vestibular fistula and posterior anoplasty—to illustrate decision-making. They review a Journal of Pediatric Surgery study showing that 20% of patients with poor sacral/spine prognosis achieved bowel control after redo surgery, while those with good prognosis did extremely well. The discussion emphasizes that mislocated anus is the most common indication for redo, and that correcting anatomy improves both continence potential and quality of life.

Key takeaways

Mislocated anus is the most common indication for redo PSARP; correcting anatomy improves continence potential and quality of life. (12:00)
20% of patients with poor sacral/spine prognosis achieved bowel control after redo; those with good prognosis did extremely well. (12:50)
Mark sphincters before opening PSARP incision to avoid misplacement—a key technical pitfall in redo surgery. (7:55)
Younger age at redo offers advantage; older patients often need concurrent Malone to learn control with new anatomy (6-12 months). (13:40)
Sacral ratio ≥0.7 predicts normal sphincters and good prognosis; higher malformations and myelomeningocele worsen continence outcomes. (6:15)

Keywords

anorectal malformation rectal prolapse prostatic fistula vestibular fistula tethered cord myelomeningocele fecal incontinence stricture posterior sagittal anorectoplasty PSARP anorectoplasty redo PSARP laparoscopic pull through cecostomy Malone

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Transcript

Click "Show Transcript" to view the full text (15137 characters)

Anal rectoplasty. It's an incredibly particular procedure and as many of you know, if you don't get it perfect, you might not have the best outcomes. And that kind of separates it from other surgical procedures. And on top of that pressure, a lot of surgeons agree that oftentimes your first shot might be your only shot to give this patient a good outcome and the right anatomy. So what happens when, despite our best efforts, the patient still has issues? Well, then we can talk about reoperating, but it's a difficult subject because how do you know when to reoperate? When's it better to just treat medically as opposed to reoperate? If this brief discussion sparked your memory and now you're thinking about a patient who didn't have a great outcome after their anal rectoplasty and you were kind of in this tough decision zone, don't feel bad because even some of the best pediatric colorectal surgeons can sometimes struggle with this. How many patients, Jason, have you seen on laxatives that comes with an anus in the wrong place? How many patients have you seen having had a cecostomy with perfect anatomy? That's the real frustrating one. Right? A lot. That's Dr. Mark Levitt at Children's National Hospital out in DC. And he's talking to his friend, Dr. Jason Frischer at Cincinnati Children's Hospital. They're talking about something that frustrates a lot of pediatric colorectal surgeons and just surgeons in general. After you've done an anorectoplasty, when do you pull the trigger and say it's time for a... Redo, redo, redo. And that's what we're going to talk about today. Anorectal malformations post-repair that might need a redo. I'm Rod Girardo from Cincinnati Children's. And this is the colorectal quiz, episode two. Well, welcome back, everyone. We're really glad you're joining us for our colorectal quizzes. This is going to be in conjunction with a review of a Journal of Pediatric Surgery article, which I'm excited to talk about as well. And really, we're here to talk about today is anal rectal malformations and post-repair. Patients who are having problems that come to your office at a few years of age and there's issues. And not only are there functional issues, but maybe anatomic issues. And so what we're putting out there proposing is to redo or not to redo. And now, Happy New Year to everyone. We missed you. Yes. Happy New Year, Jason. So yeah, you set this up really well. These are patients, we're going to present two patients, similar but different, that have had anal rectal malformation repairs in the distant past. They're now more like the age of potty training. The first one is seven years old. The second one we'll show you is four years old. And the question is, do they need something done to improve their anatomy, both from a practical point of view and from a functional point of view? Namely, improving their anatomy, will they develop bowel control? So the first case is this boy. At this point, Dr. Levitt pulls up an image of a seven-year-old male child who is status post a anal rectal plasty. If you're listening to this podcast in the Stay Current app, go ahead and open the drop box and click on the link for the first image and you can see what we're looking at. And there's some pretty obvious things that one can see. Obviously, there's a rectal prolapse. And I think anyone can just look at this image and see that the analplasty was placed too posteriorly. When we did an electrical stimulation on this patient, the center of the sphincter is in the second photo where the white dot is. Now, of importance, the original malformation was a prostatic fistula and the patient has a tethered cord and has sort of a middle-of-the-road sacral ratio of 0.66. So what would you do? Well, Mark, maybe we should discuss some of the findings. Yes, there's obvious findings of a prolapsed analplasty and a posterior position of the analplasty. But it also does maybe some other more subtle findings. Like, to me, the bottom looks quite flat. And I know you mentioned in the history that it's a rectal prostatic fistula. A patient has a tethered cord and a sacral ratio. So how do we put all that information together when discussing with the family trying to prognosticate the potential for bowel control? Yeah, I mean, I think, Jason, that's a key question. And I think all of us that are taking care of patients with anorectal malformations, and I mean, every pediatric surgeon out there needs to commit that they know what type of malformation it is anatomically. They know the quality of the sacrum and the quality of the spine, even in the newborn period. Because I can tell you, the family doesn't really care how technically elegant is your analplasty. What they care about is whether that analplasty that you make is going to work. And is the child going to be clean and in normal underwear and just like all the other kids? So prognosis is key. And I think we can tell them a lot. So what type of malformation is it? Because the higher it is, the worse the prognosis. And then the sacrum ratio, 0.7 or greater usually means... Normal connotes normal sphincters most likely or close to normal sphincters. And obviously good muscle tone and the spine innervation of that area is probably good. All of that was represented by a good sacrum. And then the nerve innervation. So keeping in mind that patients can also come with... An associated spinal anomaly, most commonly tethered cord, but the worst of course is a myelomeningocele. And those patients have much more trouble with continence. Todd Ponsky was also on the call and he caught something that both of them said really quickly and kind of brushed off. You all both looked at this image and said, you can tell obviously that this is too low, too posterior. Without a stimulator in the office, what do you look for to immediately tell that the anoplasty was done too low? But basically I'm looking for the anal dimple and there's like a midline where I say, and there seems to be a little raised area, which is where the sphincters are and where the analplasty ought to be. You know, it's amazingly common to have a mislocated anus. Is it the surgeon either misses where the center is, if they're doing a laparoscopic pull through, or if doing a PSARP, they open the PSARP incision first. And I think a key pitfall is not do that. Mark the sphincters first, then open the PSARP because then you don't get confused at the end when you're trying to place the anoplasty in the correct location. The next image comes up, this time a female, again with what appears to be a posterior anorectoplasty. If you're in the app, go ahead and click the next image. It looks, this is obviously a female, it looks posteriorly located. And what my eye is drawn to is the ellipse, the pinkish ellipse, a little bit, the white dot shows where it ought to be. The urethra and vagina are normal. So this patient was born with a vestibular fistula. The spine is normal and has an excellent sacrum. So this is a much better prognosis bowel control patient, but with a similar anatomic problem. And we have to decide whether the patient needs a redo or not. What I'm hearing you say is that visual inspection can usually tell you where this should be. Yeah, that the stimulator can confirm maybe, but you usually can tell visually about where this should be. And although you said, so that's one point. And although you said that you should mark this off first before cutting, why are people making these more posterior? How do I prevent that as someone who doesn't have the same experience you do? Yeah, so I think the answer is that you look for the visual cues, as Jason said, the ellipse, the color change, where it's a little bit indented or a little bit of a raised area, how long the perineal body makes sense. And of course, use the stimulator. And before you make any incision of any kind, then the stimulator will show you the center and then you mark that. By the way, I get asked all the time about the stimulator. It's the same electrical stimulator that anesthesia uses for their train of four. And then there's a connection that you can make that has little pins. Really, really inexpensive. And you just have to tell your anesthesiologist not to give skeletal muscle relaxant because it's a little bit weaker than the traditional stimulator, which was super expensive. The other thing, Mark, I want to mention is that when you're doing reconstructing your malformations, there are patients, the high, quote unquote, higher the malformations, let's say a bladder neck fistula in a boy, their sphincter complex isn't always where you think it's going to be. Patients like patients who have a higher malformation, such as a bladder neck, sometimes those sphincter complexes are sort of more anterior than you think that you're anticipating it might be. So really use the visual cues and the functional findings when using an electrical stimulator to put it where it should be. They pull up a recent JPS article. It's titled Assessing the Benefit of Reoperations in Patients Who Suffer from Fecal Incontinence After Repair of Their Anorectal Malformation. If you're in the app, you could just click on the link and you could read the whole article. You know, what are the benefits of doing this? Because I struggle sometimes before I really delved into pediatric colorectal surgery. I always thought that the original reconstruction was it. And of course, we want it to be right the first time, but sometimes a redo is the right thing to do. So let's discuss that. Yeah, so I just want to really give a good shout out to Richard Wood and my other partners in Columbus, because he really helped document the data on patients, on how they were when they showed up, and what happened if you redid them. So really for the first time in the Journal of Pediatric Surgery article that we're talking about here is essentially long-term outcomes in patients who have had reoperations. So let's jump in. First of all, why do patients get redos? The vast majority were mislocation. Then came stricture. And then came some less common reasons. Most relevant was a remnant of the original fistula, also known as a roof, rectal prolapse, and some others. So how did their quality of life change? Then their quality of life improved with a redo. They also had an improved ability to achieve continence. Those patients were bought to be given the best opportunity to have nearly normal anatomy if possible. So in this study, they found that 20% of the patients with a poor sacrum or a poor spine actually developed bowel control after their redo. Now those with good potential, a good sacrum and a good spine, they did extremely well. Now the remainder who did not develop voluntary bowel movements, they were still able to be clean with a bowel management program with enemas or anti-grade using a malone. Now the average age of the patients in this study is about three and a half years, give or take. Kind of raises a question. Mark, I'm going to play a little devil's advocate here. What is the right age to make these decisions? So I think if you know the anatomy is off, you should do the redo. And actually, I think there's an advantage to getting the anatomy right the younger the child is. So if there's a two-year-old and the anus is mislocated or there's a bad prolapse, then I would offer them a redo and then let them live their life in diapers for a year or two with better anatomy and then see if they can successfully potty train, knowing that if they don't, then they go to bowel management with enemas and may or may not need them alone. The one nuance is, unfortunately, many of these patients present after the age of potty training because they're incontinent. And when they're incontinent, you or I evaluate them for that incontinence and find that the reason why they're incontinent is because they don't have the best operation. Their anus isn't in the right place. They may have great sphincters, but they can't close the anal hole when they squeeze them. So we do the redo at that time. I usually add a Malone at the same time just so that they can then learn how to get control with their new anatomy before they really, really take their anatomy out for a ride and stop the Malone flushes and try to have voluntary bowel movements. That process may take 6 to 12 months. Now, the patients that we talked about had obviously misplaced anuses or ani, but what if it's kind of in between? If you see a patient who has a mislocated anus and it's 50% within the sphincter complex, so half in, half out, three and a half years old, beacly incontinent. Yeah, I think that's a good question. That's more of a philosophical question. If I was presented with that exact scenario, I would probably redo them and do a Malone and then get them perfectly clean mechanically and then see if they can develop bowel control. So I think a lot of it depends on the family's needs and the age of the patient. I might be maybe a little bit more conservative and let the child take their car out for a ride first, see how it works. If it drives well, stay with that car. If it's not driving well, then consider the redo. I mean, obviously, it's a case-by-case basis, but... I'm sort of assuming that these patients are coming to us fecally incontinent. Right. So I think the point you're making, which I think is an excellent one, is that if they haven't declared their continence yet because they're not old enough to do so from a behavioral point of view, give them a chance. They may succeed. So to summarize, Dr. Levitt and Dr. Frischer, in conjunction with this JPS article, make a really good argument that those patients who are status post their PSARP but are still having some issues with continence functionally, regardless of their original prognosis group, they might benefit from a redo. They might be able to get continence. And finally, I think this paper, which us as surgeons sometimes maybe skip this point, but I think it's the most important point, is that you improved their quality of life. Yes, it's been awesome, as always. You have anything for me? Yeah. So now I'm trying to remember what... I just learned a joke from a kid. Well, there was a child that was asking his dad an important question. He said, Dad, where does poo come from? And the father did a Google search and got some education and said, well, it's complicated. You eat and then food goes into the stomach. It's digested. Nutrition comes out in the small intestine. Water is absorbed in the colon. And then there's poo. And the child thought about that for a minute and said, okay, well, then where does Tigger come from? Oh, boy. Why don't you record a different joke if that one's no good? No, we're keeping it. Until the next time. So there you have it. The second episode in our colorectal series with Dr. Levitt and Dr. Frischer. I think they put a really good argument for a redo. Sometimes incontinence might just come down to anatomy. I'm Rod Girardo. Thanks for listening. And until next time, remember, knowledge should be free.

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