Colorectal Quiz Episode 2: When to redo a PSARP

For anorectoplasty, if you don't get it perfect, you might not have the best outcomes, which separates it from other surgical procedures.

The original malformation in Case 1 was a prostatic fistula.

The patient in Case 1 has a tethered cord and a sacral ratio of 0.66.

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.

The higher the malformation, the worse the prognosis.

A sacrum ratio of 0.7 or greater usually means normal or close to normal sphincters and good muscle tone, indicating that spine innervation of that area is probably good.

Patients can come with associated spinal anomaly, most commonly tethered cord, but the worst is a myelomeningocele, and those patients have much more trouble with continence.

Visual cues for identifying correct sphincter location include the anal dimple, a midline raised area where the sphincters are, the ellipse, color change, indentation or raised area, and appropriate perineal body length.

It's amazingly common to have a mislocated anus, either because the surgeon misses where the center is during laparoscopic pull-through or opens the PSARP incision first.

A key pitfall is opening the PSARP incision first; instead, mark the sphincters first, then open the PSARP so you don't get confused when placing the anoplasty in the correct location.

Case 2 patient was born with a vestibular fistula, has a normal spine and an excellent sacrum, indicating a much better prognosis for bowel control.

The electrical stimulator used is the same one that anesthesia uses for their train of four, with an inexpensive connection with little pins.

You have to tell your anesthesiologist not to give skeletal muscle relaxant because the stimulator is a little bit weaker than the traditional stimulator.

In higher malformations such as a bladder neck fistula in a boy, the sphincter complex isn't always where you think it's going to be and is sometimes more anterior than anticipated.

If you know the anatomy is off, you should do the redo, and there's an advantage to getting the anatomy right the younger the child is.

For a two-year-old with a mislocated anus or bad prolapse, offer a redo and let them live in diapers for a year or two with better anatomy, then see if they can successfully potty train.

Many 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—their anus isn't in the right place.

For patients presenting with incontinence after potty training age, do the redo and usually add a Malone at the same time so they can learn how to get control with their new anatomy before attempting voluntary bowel movements.

The process of learning control with new anatomy after redo and Malone may take 6 to 12 months.

For a patient with a mislocated anus that's 50% within the sphincter complex, three and a half years old and fecally incontinent, one approach is to redo them, do a Malone, get them perfectly clean mechanically, then see if they can develop bowel control.

An alternative approach for borderline cases is to let the child take their car out for a ride first and see how it works—if it drives well, stay with that anatomy; if not, then consider the redo.

If patients 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.