Imperforate Anus & Rectourethral Fistula Technique & Discussion: Difficult Cases

Today I'll talk about the elaborate surgery for male impreus with the rectal ureteral fistula, especially how to dissect the fistula to prevent post-operative cyst formation due to the radial fistula. Dissection of the valve and the prosthetic fissure is still challenging. Even in bowel fistula, we have to dissect the fistula up to the red line to prevent residual fistula without injuring nervous, prostate, urethra, and the sphincters. Recently, we developed novel technique to measure the length of the fistula, thus allowing a la surgeon to know exactly how far, how far to safely dissect distally for complete cystic excision. There are 29 male with imperference after a new technique. One vescal fistula, 14 prosthetic fistula. 9. Bulbafissula, 55, no fissula. So, 23. had rectal urethral fistula and were studied. I will show you one of the cases of prosthetic fistula. He had a right transfer colostomy soon after birth. A disal colosculum demonstrated direct ureteral fistula, and during some procedure was performed at the age of 7 months. I'll show you, this is our preferred track position for prosthetic fistula. During the laparoscopic fac dissection, the fistula was dissected, taking great care to avoid injuring the vas. A fine flexible colonoscope was inserted into the anterior rectal wall. The endoscopy of the rectum allowed both the fistula, or this and the level of laparoscopic dissection to be observed intraluminally. I think the uh, the bottom video also should be moved. So interluminally, we can observe. How we are dissecting, where we are dissecting. This is a colonoscopic view. Next, a fine catheter with a calibration was inserted through the opening by the la surgeon, whilst another surgeon performing cystoscope observed how far it emerged. At or near the Vermontum. By doing so, the lap surgeon could measure the inside length of the fistula between the fistula, opening and the urethral side orifice. Thus, the actual length of the residual fissa to be easily calculated. Ayama, let me stop you for one second. Mark wanted me to tell you that on some of your slides that had 2 videos, we made 2 slides out of it. So could you, could you back to the previous slide? Yes, I want to explain the, we'll go back, but Gama, before we play it, I just want to explain because some of your slides had 2 videos and we can only play one video at a time. OK, so we made 2 slides every time you had that. OK, could you back the previous slide? Keep going back, Mark. And could you start this video. As you can see, the lax surgeon inserted the catheter with calculations from the Erectile side of the orifice. Then we can measure the length. Residual links to the residal fistula. Could you move to another nexus video? You know, At the same time, The surgeon who was doing a cystoscope can see the tip of the catheter, which was inside it, from the rectal site of the fistula. As you saw in the previous slide, then. If the length of the resal fissure was longer than 5 millimeters, the rectal end was further dissected toward the urethra. Using a mucosectomy. The mucoectomy to prevent injury of the prostate and the urethra. This procedure was repeated until the length of the residual fistula was shorter than or equal to 5 millimeters. The fistula was ligated, tied, and excised. Could you start the video here, here. There's one video here. Is there supposed to be a second video, Yama? No, I don't think so. There's one video here. We're watching the video. Oh, you're watching a video. Yeah, you're snaring with the endo loop right now. Now, now, now, now I can see the video. Yes, OK. We have to repeat the procedure until the residual fistula is less than 5 millimeter, then we tied and excise the fistula. Hello? Next, uh, I'll show you the uh one of the cases of bulbar fissula. Can you see the slide? This is bulbafisula. Yes, yes, we see it. Yeah, we see it. Yeah, I do this through the use of tube. You know, for bulbar fistula, it is very important and very advantageous to obtain as clear a surgical field of the deep pelvic floor as possible, otherwise we cannot operate. I do this through the use of a tube tube vasostomy, which decompress the bladder, nicely and opens up a clear view of the deep pelvic floor. This is the important procedure. Troka position for rectal bowel fistula differs from that for prosthetic fistula in that right and left strokers are placed much closer to the telescope compared to prosthetic fistula. This is also key for bulbar fistula. There is a new device that allows the telescope to be adjusted to face any direction from 0 to 120 degrees interoperatively, and it allows the sergeant freedom. Choose the best view without disrupting a dissection. In order to Me Despite the increased difficulty in handling the forceps in this position, it allowed the tips of the forceps to reach. Deeper and to reach the Balva. urethra, which is located deep in the pelvis. In order to measure the length of the bala fistula. As you saw in the, in a previous slide, we did the same procedure, to measure the residal fistula. That is the same procedure in the same as the prosthetic fistula. Then, after the balva fistula. Was dissect free, the fistula is tied and excised. After the fistula is tied, a catheter is again inserted until it gently probes the tied fistula. As shown in the video, thereby allowing the surgeon to, could you back to the previous video. Yeah, we'll go back. Yeah, we'll go back and show it. This is a very important video. A catheter is again inserted until it gently probes the tied fistula, thereby allowing the surgeon to reconfirm that the residual fistula length is shorter than or equal to 5 millimeters. We can check from the urethral site. The fistula is already tied. Then the catheter didn't go more than 5 millimeters. So around 2 to 3 millimeters. This is our results. Here are results showing the first eight cases from the initial measurements of the rectal to urethra orifice, the fistula was 1315, 1210, 1521, 10, 5 millimeter respectively. The 7 cases required further dissection until the fistula shorter than or equal to 5 millimeter, but the case 8 did not require further dissection. During cystoscope, normal saline reflux into the pelvic floor. Through the fistula in 6 cases, this is interesting, indicating the fistula is large, however, there is no reflux in 2 cases indicating that the fistula is very, very narrow. All are well after mean follow up of 2 years, with no evidence of diverticular formation owing to resal fistula on graph, urethrography, or MRI in all 23 cases. All dissections were uncomplicated. And the post-operative courses were unremarkable. The residual fistula from rectal site to urethral cyt much longer than expected. Our new technique measuring the exact length of the fistula facilitates a safe and complete excision of the fistula, thus reducing the risk of postoperative diverticulum formation due to incomplete fistula excision. Thank you for your attention. Thank you, Yama. And let me just make a comment. I apologize. You know, in Yama's original talk, he was showing two of those videos together so you can see the two views simultaneously, which really. Explains the technique and, and unfortunately, we couldn't do both videos, but I wanted to point out that that's really where you better understand exactly this technique. I loved it. I thought, uh, I've never used this. I'm wondering, for those of you out there, let's first open it up. Uh, if anyone in the virtual faculty wants to make a comment, raise your hand and we'll call on you. Um, otherwise, I'll open it up to the studio faculty here. Um, and actually before I do that, I know that Doctor Jaafar, are you on the phone? Dr. Jaafar. All right. I know he was on the phone and he had a question. If you want to call back in, Doctor Jaafar, we can let you ask your question to uh Professor Yamataka, uh, Bob, did you have any comments? Yeah, I, I, I absolutely tremendous, and I think, uh, one of the, this isn't trick, trick of the trade. This is like 50 tricks in one presentation. There's so much, uh, in here that's, uh, super interesting. I, I, there's a couple of pieces I have. Certainly one is, I mean, how do you find this many, uh, prosthetic, uh, Uh, fistulas to be able to test this on, which is great. I think the lesson to me was how long this fistula is when we, when you actually, uh, dissect it out. The technique of measuring it is fantastic. My questions, I think, are more, when do we think we can use this as the general laparoscopic public? There's a number of skills here that are, are fairly advanced, particularly as We got to the retro, uh, the rectal bulbar fistulas, um, and when is the crossover to doing it in a traditional posterior approach on these very low ones, more advantageous. It looks like the prosthetic ones, so it may be a bit easier, but bringing in the endochameleon type things and things like that are, they're demanding for people. I just wonder what you think of the general laparoscopic public, when should we be doing this? Thank you for your comment. Firstly, you know, as you can imagine, balder fistula is, you know, dissection is very difficult, so I recommend vesical and high prosthetic fistula first, and But uh, in a case with uh uh prosthetic fistula, I think uh as far as, you know, labors surgeon has a uh you know, training for gallbladder removal or other, you know, fundamental technique, I think, ah, ah, they can do that. But, ah, if the, the key for dissection of the fistula is the compression of the bladder. So I have, uh, you know, many experience of, uh, uh, urology. So I'm familiar with the technique of, uh, a cystoscope and, uh, inserting the, you know, tube cystostomy. We call, ah, you know, suprapubic catheter if, ah, Uh, la surgeon, the technique is still not good enough. I think, uh, I recommend insert the tube vasostomy first to. For complete decompression that allows You know, Give us a good view of the pelvic floor. Then I think, ah, for dissection of the prosthetic fistula it, ah, I think, ah, they can do that, but, ah, maybe for bulbar fistula dissection. I think, uh, you know, labor surgeon needs 5 to 10 cases of the, ah, prosthetic fistula. Then they can challenge to bowel fistula. But as I mentioned before, the trocha position should be very, very close to the, ah, telescope, otherwise tip of the instrument cannot reach to the deep side of the pelvis. So I mean, ah. tip of the catheter cannot reach to the bowel of fistula. Excellent. OK. Any other comments or questions? I know Jack Langer wanted us to poll the audience to see who here is doing laparoscopic analectal malformations. So please go ahead and answer that poll, whether or not you're performing laparoscopic, you know, rectal malformations. And then Mark, after each of these tricks, if we could also put a poll up saying, do you use this trick? And if not, the second poll, would you use this trick? So we'll do that as well. Um. I think, uh, yeah, Jose, go ahead. Yama, that's awesome as always. Do you, uh, do you do other traction sutures or other stay sutures on the bladder? Is there stuff happening off the screen that we're not, we don't, because you focused on the more distal part? Yes, correct, I think it's often that we use the, uh, you know, traction sutures, and do you know the LA LA hair closure needle? Yeah, we use 2 to 3 traction sutures to bring the blood up. There was, there was a question from uh Jeffrey Pence. Is a right transverse colostomy typically constructed in your practice? Do you do right transverse colostomies typically? Um, and he says, go ahead, Yama. I do because You know, some surgeons make the, uh, you know, sigmoid sigmoid colostomy, so, and I found sometimes, uh, we, we cannot, uh, uh, make the, uh, you know, enough length for periphery of the rectum because the, uh, sigmoid colostomy fix the, you know, I don't know how to say the, uh, sigmoid colostomy fix the, uh. Ah, rectum and the colon, so we have to take them down the sigmoid colostomy to for You know, putting it through the distal end of the fistula. That's why I prefer a right to transfer colostomy. Can make a comment? Yeah, go ahead. Yeah, so, um, Just on the topic of where the colostomy is done, I, I think there are advantages and disadvantages to a transverse colostomy versus a sigmoid colostomy. I, I prefer a sigmoid colostomy, and I think if you do the sigmoid colostomy very proximal in the sigmoid or even at the descending colon sigmoid junction, uh, you will have enough length to, uh, to do a pull through even for a high fistula. I, I guess I want to be, I'm sorry, you wanted to say something, Ya, but, but how do you find the very proximal of the sigmoid column at the time of the operations when you are making colostomy? How do I find it? Yeah, how to find out the very proximal side of the sigmoid sigmoid to make the uh proximal sigmoid. Yama Yama, I'm using laparoscopy sometimes to, uh, to help to make those initials. Oh, you're using the laparoscopy to make the coloscopy original colostomy so I can see exactly where I am. And if I do it open, I, I find those the traction point along the descending colon and make sure I'm close to that point. I make the left lower quadrant transverse incision and uh just pull out the sigmoid and figure out which end is which and just go proximal. Sharif Emil, I see you typing stuff. Did you want to make a comment? Sorry, Todd, I missed most of the presentation because I'm having a lot of um difficulties with the program shutting down and rebooting all the time. Um, we, we're just making a point about a transverse colostomy really having too many problems, um, both in terms of, uh, urine absorption and infection and prolapse that I, I think it's uh, I would bet if you polled the audience that. A very small minority would still be using transverse colostomies at this point. OK, Mark, can we put a poll up? Um, who is, are you, are you using transverse colostomies? Um, and then we can pull the audience on that. Um, go ahead. What's that, Jose? Raise my hand. Should I do it on the line? I, uh, I just wanted to say, I think even with the, um, sigmoid colostomy, um, it's, it's possible, uh, to place your ports and work around the stomas without having to take them down and do the deep pelvic dissection. So I have not found them typically to be a problem, and I wonder, Yama, since you're putting your port so much closer to the umbilicus, if it becomes even less of an issue with those deep, um, uh, bulbar fistulas. Sorry, sorry, could you say, could you say again the question? The a sigmoid colostomy on the left side with your, as you described your ports for the for the bulb. Yeah, you're right, yes, yes, you're going to be more midline anyway, so it would seem to me less whether you have a, you're right. That is another reason I don't like the sigmoid colostomy because if there's a sigmoid colostomy on the left side and you know it would be an obstacle for inserting the truck cars. Actually that's not really a problem. You can just go in the left upper quadrant and go around lateral to the colostomy. Uh, it's not an issue. I wanted to, um, to challenge this technique though. Just I, I know everybody's like, uh, you know, really positive about it, but I. I think that for a prostatic or bladder neck fistula, you can do that dissection without this technique and get very, very close to the end of the fistula. I think you're right. If the, uh, you know, labor surgeon is getting familiar with the, you know, a laparos aneurysthal malformation operations like you, I think we don't need this art technique, but for balva fistula, I think, uh. You know, I feel still we need these procedures, and that's probably true, but I would question whether the laparoscopic approach is the correct approach for a bulbar fistula. It's, it's far more difficult. I think it's more dangerous. The technique you've described is extremely complicated for the average pediatric surgeon, and the PSARP technique is easy for those patients. And as far as I am aware, there really isn't any convincing data that the laparoscopic approach. Uh, results in any better outcomes for Balbar fistulas than the peace ar does. The reason why I simply, you know, stick to the laps procedure, even for bulbar fistula, uh, simply, I do not want to cut the sphincter of, you know, anus. I, I just, I just do not want to do damage to the muscle and the nerves for sphincters. Yeah, I, I get that, but, but where are the data? Yeah, so, you know, we, we have to. That's the age-old, uh, the question that we all don't know. Yeah, Bob, and if, uh, I'm with you, I think you're asking a lot of someone to be doing these very low ones, but critical to this is getting a good fistulagram at the beginning. Yours were very pretty in this. Do you have any tricks that you do to get those fistulagrams so nicely, because that can make a big difference deciding what, what you should do. Are you asking how to do the colossogram? Yes, I mean, do you have a, I think. Yeah, colostogram is, you know, very important to, for studying the uh laparoscopic dissection. So, some, sometimes, uh, if we cannot get the good view for fistula, I think I repeat it. And also sometimes before operation, I do colonoscopy. If There's a, you know, doubt whether the patient had a fistula or not. We can do colonoscopy through the transplants colostomy, and also we can do the cystoscope. Sometimes we can combination of colonoscope and the cystoscope before operation if the colostogram did not show the nice anatomy of the fistula. Yeah, that's great because I think in the general world that the lesson would be, at least to me, is that, you know, doing the high ones are are it's very helpful to have your laparoscopic approach. Getting low, I think the PAP is still, you know, for many of us the way we should be thinking and it's trying to decide beforehand before you know which one you're. I, I would just add to the, the colostogram. It's, uh, we, we combine a, a VCUG and colostogram at the same time. So if you put the dye in from both sides, usually you can see the fistula pretty clearly. The other point I just wanted to emphasize that Yama made earlier, but I, I want to make sure that it's not lost, and that is how important it is to have an empty bladder when you're doing a laparoscopic, uh, anorectal malformation repair. And sometimes, uh, when you put the Foley in at the beginning of the case, it goes into the fistula and into the rectum, not into the bladder, and you may not know that until you're in the middle of the operation and then you, actually, I did one the other day where we came across the fistula and hey, there, there's the Foley, it's actually not in the bladder. So, I think, um, it's probably a good idea to cystoscope all of these kids at the beginning of the case, make sure that the catheter is actually in the bladder before you start the case. And also when we are doing the cystoscope, we have to, you know, you know, inject the saline. So the compression for the bladder, we need, uh, uh, you know, tube tube vasostomy. Otherwise, you know. bladder will be filled full filled with saline, so we cannot see in the pelvic floor. That's why for val facial dissection, we need a tube of vasostomy to decompress the bladder, especially when we are doing cystoscope. All right.