IPEG 2020 TOP ABSTRACT: Primary rectourethral fistula repair in a 17 year old male
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More about congenital rectourethral fistula
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What the experts said
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 are somewhat different in a 17-year-old compared to 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
With the patient's airway improved after tracheal surgery, attention was turned to his urologic system to eliminate ongoing risk
Based on preoperative VCUG, the distance between anal dimple and fistula was estimated to be 3 to 4 centimeters
Because of the anticipated amount of rectal mobilization, a combined abdominal and perineal approach was chosen, utilizing robotic assistance for dissection of deep pelvic structures
Cystoscopy demonstrated a broad-based low prostatic rectourethral fistula
The mesorectal plane was followed past the peritoneal reflection into the pelvis until the rectum narrowed as it approached the prostate
The robot system's integrated fluorescence camera, when used without dye, was helpful in identifying 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 what was viewed intraabdominally
The common wall between rectum and prostatic urethra was taken down sharply with scissors to avoid leaving a posterior urethral diverticulum
The fistula was closed in two layers using running vicryl suture
After filling the urethra with saline, no leak was seen
The pelvic floor was opened and dilated to a size 24 Hagar
The rectum required a small amount of proximal mesenteric release to bring it down without tension
The completed anorectoplasty easily accommodated a 22 Hagar 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