Posterior Rectal Advancement Anoplasty (PRAA) in a male with an anorectal malformation and rectoperineal fistula
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
In males with rectoperineal fistula, the good rectal lumen is only millimeters below the anal skin where the anoplasty needs to be
Urethral injury is a complication that is surprisingly easy to do during operations for rectoperineal fistula
The urethra is very close to the rectal wall in males with rectoperineal fistula
Traditional posterior sagittal anorectoplasty (PSARP) with full thickness circumferential mobilization of the rectum can lead to urethral injury
With PRAA, no dissection at all is done for the anterior rectal wall
The fistula opening in males is always located at the anteriormost part of the sphincteric ellipse, within the ellipse not outside of it
The fistula runs in a subepithelial plane into the scrotal raphae in some males
The rectal lumen lies right below the surface at the anteriormost part of the sphincter
The midline incision should not go any farther posterior than the intended anoplasty to avoid having any posterior sagittal incision to close or heal
Muscle fibers below the skin triangles should be preserved during dissection
The anterior rectal wall is not touched during PRAA
The Lone Star retractor is very helpful to set up this case
Lateral dissection is kept full thickness along the rectal wall with the rectal wall remaining intact
Mobilization adequacy is checked by determining if healthy mucosa can easily reach the skin for anoplasty with no tension
Not touching the anterior wall prevents any potential injury to the urethra, previously the most feared complication of this operation
1 to 2 millimeters of fistulous tissue is trimmed on the lateral sides
The PRAA technique preserves the dentate line in the anal canal