IPEG 2020 TOP ABSTRACT: Primary rectourethral fistula repair in a 17 year old male

Congenital rectourethral fistula is a well-recognized type of anorectal malformation.

Patients with rectourethral fistula generally undergo repair in the infant period, although repair is sometimes delayed into early childhood due to associated comorbidities or social situations.

Operative repair considerations for rectourethral fistula in a 17-year-old are somewhat different from repair in an infant or child.

The patient had frequent urinary tract infections and often leaked urine out of his mucous fistula.

The patient was deemed too high risk for fistula repair due to his tracheal stenosis.

Based on preoperative VCUG, the distance between the anal dimple and the fistula was estimated to be 3 to 4 centimeters.

A combined abdominal and perineal approach with robotic assistance was chosen due to the anticipated amount of rectal mobilization.

Cystoscopy demonstrated a broad-based low prostatic rectourethral fistula.

The robotic fluorescence camera, when used without dye, can help identify the light from the cystoscope from the abdominal view, confirming the location of the fistula.

Cystoscopic identification of the fistula base demonstrated an additional 1 to 2 centimeters of fistula between the base and the intraabdominal view.

The common wall between rectum and prostatic urethra was taken down sharply with scissors to avoid leaving a posterior urethral diverticulum.

The urethral fistula was closed in two layers using running Vicryl suture, and saline leak test showed no leak.

The pelvic floor was dilated to a size 24 Hegar dilator.

The rectum required a small amount of proximal mesenteric release to bring it down without tension.

The completed anorectoplasty easily accommodated a 22 Hegar dilator.

The patient was extubated postoperatively and weaned quickly to room air.

The Foley catheter will be left in place for 2 weeks to protect the urethral repair.

Primary repair of rectourethral fistula is quite different in adult-sized patients than in a child, although the basic principles remain the same.

The robotic system was very helpful for deep pelvic dissection.

The intramural fistula length was longer than anticipated, highlighting the need for concomitant visual assessment of the urinary tract.

The fluorescence camera can be helpful in visualizing the location of the cystoscope from the abdominal viewpoint.

Performing the anorectoplasty in lithotomy position is challenging but eliminates the need to change to prone positioning for perineal work, which is helpful in adult-sized patients.