Surgical Management Of Female Anorectal Malformation Patients Including...
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 every single redo of a female anorectal malformation, areolar tissue is found that had never been dissected by the original surgeon, suggesting inadequate anterior rectal wall mobilization led to perineal body disruption.
The rectal blood supply is intramural, so injuring the rectal wall during dissection hurts its blood supply.
About 2 to 5% of vestibular fistulas have a vaginal septum that should be identified at the time of rectal repair.
Of 33 patients with vestibular fistula and absent vagina, 75% had urologic problems including neurogenic bladder, and 50% had CKD stage 3 or greater.
Vestibular fistula with absent vagina requires aggressive urologic screening due to high rates of solitary kidneys, reflux, hydronephrosis, neurogenic bladder, and urinary tract infections.
The ideal time to create a neovagina is when fixing the rectum, because the perineal body is open and the sigmoid pedicle reaches more easily in younger children with shorter pelvis.
About 50% of cloacas have a bifid gynecologic system.
Catheterization of cloaca should be done under ultrasound guidance initially to ensure the catheter enters the correct structure (right vagina, left vagina, bladder, or rectum).
Most patients with hydrocolpos can be successfully drained by draining the hydrocolpos only, without needing to drain the bladder separately.
Starting lateral dissection before attempting to separate the common anterior wall is key; the lateral plane defines the anterior plane.
Coming in from lateral to anterior and starting more proximally (where structures are easier to separate) rather than at the perineum improves the dissection plane.
A systematic review found that early enteral nutrition appears better than later nutrition in anorectal malformation repair, but all studies were retrospective and poor quality.
Women with longitudinal vaginal septum often learn to work around it for intercourse and may be asymptomatic, but menstrual hygiene (tampon use) is a major reason for resection.
Vaginal septum resection in adolescents is not a difficult operation and can be done with electrocautery, getting as close to the cervix as possible without damaging it.
For absent vagina with vestibular fistula, sigmoid neovagina is preferred, using sigmoid colon mobilized laparoscopically and brought to the perineum, with backup colostomy.
If a vaginal septum is found in a 6-year-old after anorectal malformation repair, there is no rush to remove it before puberty unless another operation is planned.
For newborn cloaca with hydrocolpos, an open divided colostomy should be performed, and the vagina decompressed with a pigtail catheter rather than formal vaginostomy.
Cystoscopy at the time of colostomy creation in cloaca makes the colostomy creation very difficult and should be avoided; scope at 2–3 months instead.
Intermittent catheterization of the cloaca 2–3 times daily can drain urine from the vagina and avoid the need for vaginostomy tube in many cases.
In hydrocolpos compressing the ureters, once the hydrocolpos is drained, the bladder fills beautifully, demonstrating the physiology of ureteral compression.