Tricks - Imperforate Anus and Rectourethral Fistula
With Dr. Jeff Blair · StayCurrentMD
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
Dissection of the fistula up to the red line is necessary to prevent residual fistula without injuring nerves, prostate, urethra, and sphincters
23 male patients with rectourethral fistula were studied: 1 vesical, 14 prostatic, 9 bulbar, 5 no fistula
A fine flexible colonoscope inserted into anterior rectal wall allows observation of both fistula orifice and level of laparoscopic dissection intraluminally
A calibrated catheter inserted through the fistula opening while another surgeon performs cystoscopy allows measurement of inside fistula length between rectal opening and urethral orifice
If residual fistula length is longer than 5mm, the rectal end is further dissected toward urethra using mucosectomy to prevent injury of prostate and urethra
The measurement and dissection procedure is repeated until residual fistula length is ≤5mm, then fistula is ligated and excised
For bulbar fistula, tube vesicostomy to decompress bladder is very important to obtain clear surgical field of deep pelvic floor
For bulbar fistula, right and left trocars are placed much closer to telescope compared to prostatic fistula, which is key for reaching deep pelvic structures
After fistula is tied, catheter is reinserted to gently probe tied fistula, allowing surgeon to reconfirm residual fistula length is ≤5mm
In first 8 cases, initial fistula measurements from rectal to urethral orifice ranged from 5-21mm; 7 cases required further dissection, 1 did not
During cystoscopy, normal saline refluxed into pelvic floor through fistula in 6 cases (indicating large fistula), but no reflux in 2 cases (indicating very narrow fistula)
All 23 cases had no evidence of diverticular formation due to residual fistula on voiding urethrography or MRI after mean 2-year follow-up
The residual fistula from rectal site to urethral site is much longer than expected
Sigmoid colostomy placed very proximal in sigmoid or at descending-sigmoid junction provides enough length for pull-through even for high fistula
Transverse colostomy has too many problems including urine absorption, infection, and prolapse
With sigmoid colostomy, it is possible to place ports and work around stomas without taking them down for deep pelvic dissection
For prostatic or bladder neck fistula, dissection can be done without the measurement technique and get very close to end of fistula
For bulbar fistula, the measurement technique is still needed
The laparoscopic approach for bulbar fistula is far more difficult and dangerous; PSARP technique is easy for those patients
There is no convincing data that laparoscopic approach results in better outcomes for bulbar fistulas than PSARP
Combining VCUG and colostogram with dye from both sides usually allows clear visualization of fistula
Empty bladder is critically important when doing laparoscopic anorectal malformation repair
Foley catheter placed at case start may go into fistula and rectum rather than bladder, which may not be discovered until mid-operation
Cystoscopy at case start is advisable to ensure catheter is in bladder before starting
Tube vesicostomy is needed to decompress bladder during cystoscopy, otherwise bladder fills with saline and obscures pelvic floor view
For thoracoscopic TEF repair, gap between proximal and distal esophagus should be checked preoperatively
Bronchoscopy by anesthesiologist can identify fistula orifice; X-ray taken with bronchoscope stopped at orifice shows gap distance (approximately one vertebra in presented case)
Leaving one quarter of fistula uncut prevents distal esophagus from retracting cranially and makes anastomosis easier
Leaving 12-15% of proximal esophageal tip uncut provides a 'cap' to grab with forceps rather than grabbing anastomotic site
If there is 1-3 vertebra gap, assistant can pull proximal esophagus caudally using the uncut cap
First anastomotic stitch is placed in middle of posterior wall rather than at edge
Tracheoesophageal fistula is completely divided after 1-2 anastomotic stitches are placed
Uncut cap of proximal esophagus is divided after 2-3 anastomotic stitches, avoiding touching the anastomotic site itself
Transfixing suture to close fistula prevents it from coming off; clips tend to hook behind sutures
For type C esophageal atresia with considerable gap, two sutures can be placed and made into sliding knots to slowly bring ends together, dividing tension between two esophageal ends
Clips may erode or be implicated in fistula recurrences
If fistula clip is applied very tightly, it will crush muscle and erode, causing fistula recurrence; clip should just oppose rather than crush