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Dr. Todd Ponsky

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Pediatric Colorectal Contraversies Part III: Pediatric Colorectal...

Video Published 2018-09-16 Updated 2026-06-10

Timestops (8)

PSARP versus Laparoscopy Debate

Case Review: Three Distal Colostograms

Surgical Approaches for Bulbar Fistulas

Laparoscopic Technique for Low Fistulas

Indications and Patient Selection Criteria

Comparative Case Analysis and Polling

Robotic Surgery and Future Technology

PSARP Safety and Vestibular Fistulas

Topic Overview

A panel discussion comparing posterior sagittal anorectoplasty (PSARP) versus laparoscopic approaches for anorectal malformations. The discussants emphasize that surgical goals—finding the distal rectum, managing the fistula, mobilizing the rectum with intact blood supply, and placing it within the sphincter mechanism—matter more than the specific approach. Key clinical points include: laparoscopy is preferred for high (bladder neck/prostatic) fistulas but offers limited benefit for bulbar fistulas where PSARP provides superior exposure; anal stenosis occurs in approximately one-third of laparoscopic cases; posterior urethral diverticula with retained metallic staples are a recognized complication of laparoscopic repair; and a hybrid "laparoscopic-assisted PSARP" technique is advocated to combine the advantages of both approaches. The panel stresses that outcome comparisons must specify the exact malformation type (bladder neck, prostatic, or bulbar fistula) and document sacral and spinal quality, as prognosis depends on these anatomic factors regardless of surgical technique.

Key Takeaways

Laparoscopy preferred for high (bladder neck/prostatic) fistulas; PSARP superior for bulbar fistulas due to better exposure. (2:16)
Anal stenosis occurs in ~1/3 of laparoscopic cases, possibly from long dissection lines and inadequate postop dilation. (2:40)
Posterior urethral diverticula with retained metallic staples are recognized complications of laparoscopic repair. (11:14)
Hybrid laparoscopic-assisted PSARP combines transabdominal mobilization with posterior sagittal sphincter placement. (13:10)
Prognosis depends on malformation type, sacral quality, and spine status—not surgical approach—if operation done well. (1:01)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Mark — host
ALP — guest
Yama — guest
Longley — guest
Doctor Pena — guest
Evo — guest

Chapters

0:01PSARP vs Laparoscopy: Goals and Literature Critique — Introduction to the controversy, emphasizing that surgical goals (finding distal rectum, managing fistula, mobilizing rectum, placing within sphincter) are paramount regardless of approach. Critique of existing literature for failing to document malformation type and sacral/spinal status.
3:19Panel Discussion: Approach Selection by Fistula Type — Panelists discuss their approach to three distal colostogram cases. Consensus emerges that bulbar fistulas are better suited to PSARP, while bladder neck fistulas are appropriate for laparoscopy. Technical details of laparoscopic dissection and fistula management are shared.
8:03Advantages, Complications, and Future of Laparoscopy — Discussion of laparoscopy advantages (avoiding laparotomy pain), complications (anal stenosis, posterior urethral diverticula with metallic staples), and future directions including robotic surgery. Emphasis on proper patient selection and outcome reporting standards.
11:42Rectal Anatomy, Hybrid Technique, and Posterior Sagittal Incision — Analysis of two similar fistulas with different rectal anatomy. Introduction of laparoscopic-assisted PSARP hybrid technique. Defense of the posterior sagittal incision as safe and non-damaging to sphincters when performed in the midline.

Key claims

0:22Surgical goals for anorectal malformations are to find the distal rectum, manage the fistula, avoid leaving distal rectum behind, mobilize the rectum with good blood supply, and place it within the sphincter mechanism — Mark
0:46Literature comparing PSARP to laparoscopy almost never comments on the exact malformation type or the status of the spine or sacrum — Mark
1:01Without knowing the exact anatomy and the status of the sacrum and spine, you cannot make judgments about the prognosis of a patient — Mark
1:51In a series of 24 laparoscopic cases, bulbar fistulas are no longer approached laparoscopically because the benefits do not justify the longer operative time compared to PSARP — ALP
2:16Bladder neck fistulas are approached with laparoscopy as it is a nice easy way of doing it — ALP
2:40Anal stenosis at the cutaneous junction level occurred in approximately one in three laparoscopic patients, requiring anoplasty — ALP
2:59Long dissection line and ischemic changes may have contributed to anal stenosis in laparoscopic cases — ALP
3:08Poor follow-up and inadequate dilatation programs contributed to anal stenosis in a 24-case laparoscopic series — ALP
3:49During laparoscopic dissection, a catheter is placed from the rectal side of the fistula orifice into the urethra to measure residual fistula length and guide dissection until the fistula is divided approximately 5 millimeters from the urethra — Yama
4:39For low fistulas, a combined approach using laparoscopy and modified PSARP keeping the sphincter intact is preferred because it is difficult to close the fistula and remnants could cause post-operative diverticulum — Longley
5:56For rectal bulbar fistula, grasping the distal rectum makes the fistula become shallow and accessible from the abdominal cavity, allowing dissection of the mucosa while leaving the muscular cuff intact to avoid nerve damage — Longley
6:58If the mucosa is resected completely to the most distal part of the rectum, urethral fistula rarely occurs after laparoscopic operation even without ligation or suturing of the fistula — Longley
7:27All three fistula types (bladder neck, prostatic, bulbar) are indicated for laparoscopic approach with results comparable to posterior sagittal approach — Longley
8:15Current laparoscopic instruments are grotesque and rude, but refined instruments are expected in the future — Doctor Pena
9:12When discussing anorectal malformations, the archaic classification into high, intermediate, and low should not be used — Doctor Pena
9:36Evaluation must include the quality of the sacrum and whether the patient has tethered cord when comparing results — Doctor Pena
9:55The advantage of laparoscopy is avoiding laparotomy and the associated pain — Doctor Pena
10:12Some prostatic fistulas that appear accessible on distal colostogram may be more accessible laparoscopically than from below — Doctor Pena
10:56Bulbar fistula repair via PSARP takes approximately one and a half hours with minimal pain, same-day oral intake, and 48-hour discharge with excellent results — Doctor Pena
11:14Patients referred after laparoscopic repair of bulbar fistulas have presented with huge posterior urethral diverticula and metallic staples in the pelvis with associated complications — Doctor Pena
12:06Smaller rectums with prostatic fistulas are easier to dissect and free from the urethra laparoscopically — Evo
12:26Larger rectums are easier to access from below via PSARP — Evo
12:51Bulbar fistulas are more easily approached from below because they are very close and do not require a laparoscope — Evo
13:00Smaller fistulas, especially bladder neck and prostatic fistulas, are appropriate for laparoscopy — Evo
13:10Laparoscopy is combined with a small PSARP incision (mini PSARP) to place the rectum exactly in the sphincter and muscle complex — Evo
13:48When the rectum is very low and bulging, it is very difficult transabdominally to dissect the distal rectum elegantly, mobilize enough rectum, and avoid urethral injury, whereas posterior sagittal provides beautiful exposure — Mark
14:15A high rectum is easier to access transabdominally and laparoscopy is the perfect route for that anatomy — Mark
14:38When discussing cases, the fistula type (bladder neck, prostatic, or bulbar), sacral quality, and spinal quality must be documented to allow meaningful comparison of results — Mark
14:59Patient prognosis is based on the malformation type, spine quality, and sacrum quality regardless of surgical approach, provided the operation is done well with adequate rectal mobilization, fistula disconnection, and no retained distal rectum — Mark
15:41Robotic surgery provides a fantastic three-dimensional view and allows reproduction of hand movements and fine instrument control through digital instruments — Doctor Pena
16:17The future of laparoscopy involves digital instruments that enable fine movements for quick and safe operations — Doctor Pena
17:20In laparoscopic-assisted PSARP, the procedure starts with laparoscopy to mobilize the distal rectum and ligate the fistula, then the legs are lifted over the baby's head (not returning to prone position) and a posterior sagittal incision is made — Mark
17:42The posterior sagittal incision is the safe way to get into the perineum; making a tiny anal incision creates a more dangerous operation — Mark
17:52Most injuries have occurred because of blind maneuvers to get into the pelvis — Mark
18:20The sphincters do not cross the midline; if the surgeon stays perfectly in the midline and reconstructs them, they work — Mark
18:28Patients who had vestibular repairs and trans-anorectal approaches with completely split and reconstructed posterior sagittal incisions remain perfectly continent — Mark
18:43The posterior sagittal incision allows tacking the rectum to the posterior edge of the muscle complex, which helps avoid prolapse — Mark

Points of disagreement

1:51Use of laparoscopy for bulbar fistulas
- ALP: No longer uses laparoscopy for bulbar fistulas after initial 24 cases; benefits do not justify longer operative time
- Longley: Uses laparoscopy for all three fistula types including bulbar with comparable results to PSARP
- Doctor Pena: Against laparoscopy for bulbar fistulas; PSARP is faster with minimal pain, same-day feeding, and excellent results
- Evo: Prefers PSARP for bulbar fistulas because they are easily accessible from below and do not require laparoscopy
4:39Optimal technique for low/bulbar fistulas
- Longley: Advocates combined laparoscopic approach with modified PSARP keeping sphincter intact to avoid leaving remnant fistula
- Yama: Uses laparoscopy even for low fistulas with catheter-guided dissection to divide fistula close to urethra
- Mark: Advocates laparoscopic-assisted PSARP hybrid technique combining advantages of both approaches

Open questions

What is the optimal follow-up protocol and dilatation program to prevent anal stenosis after laparoscopic repair?
How can ischemic changes during laparoscopic dissection be minimized to reduce stenosis risk?
What are the long-term functional outcomes of laparoscopic-assisted PSARP compared to traditional PSARP or pure laparoscopy?
When exactly is a prostatic fistula more accessible laparoscopically versus from below based on distal colostogram appearance?
What is the role of robotic surgery in anorectal malformation repair as the technology and instruments improve?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Laparoscopy versus PSARP for Bulbar Urethral Fistulas: Four Surgical Perspectives

The points where the speakers disagreed, with each position presented side by side. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Points of disagreement · AI-written, human-reviewed

The Question

When a male infant with anorectal malformation has a bulbar urethral fistula — the rectum opening into the bulbar urethra, visible on distal colostogram as a low connection — should the repair be performed laparoscopically or via posterior sagittal anorectoplasty?

The Case Against Laparoscopy for Bulbar Fistulas

One discussant abandoned laparoscopy for bulbar fistulas after an initial series of 24 cases 1:51. The benefits did not justify the longer operative time compared to PSARP 1:51. In that series, anal stenosis at the cutaneous junction occurred in approximately one in three patients, requiring anoplasty 2:40. Long dissection lines and ischemic changes may have contributed, though poor follow-up and inadequate dilation programs also played a role 2:59 3:08.

Another discussant opposes laparoscopy for bulbar fistulas on efficiency grounds 10:56. PSARP is brief with minimal pain, same-day oral intake, and early discharge with excellent results 10:56. More concerning, patients referred after laparoscopic repair of bulbar fistulas have presented with huge posterior urethral diverticula and metallic staples in the pelvis with associated complications 11:14. "We have a series of patients that we receive from surgeons who use laparoscopy in those patients and they refer the patients to us with a huge posterior urethral diverticulum and metallic staples in the pelvis with all the complications that you can imagine about that" [q6].

A third discussant agrees that bulbar fistulas are more easily approached from below because they are very close and do not require a laparoscope 12:51. When the rectum is very low and bulging, it is very difficult transabdominally to dissect the distal rectum elegantly, mobilize enough rectum, and avoid urethral injury, whereas posterior sagittal provides beautiful exposure 13:48.

The Case for Laparoscopy Across All Fistula Types

One discussant uses laparoscopy for all three fistula types — bladder neck, prostatic, and bulbar — with results comparable to PSARP 7:27. For bulbar fistulas specifically, grasping the distal rectum makes the fistula become shallow and accessible from the abdominal cavity, allowing dissection of the mucosa while leaving the muscular cuff intact to avoid nerve damage 5:56. If the mucosa is resected completely to the most distal part of the rectum, urethral fistula rarely occurs after laparoscopic operation even without ligation or suturing of the fistula 6:58.

Another discussant uses laparoscopy even for low fistulas, employing a catheter-guided technique: during dissection, a catheter is placed from the rectal side of the fistula orifice into the urethra to measure residual fistula length and guide dissection until the fistula is divided approximately 5 millimeters from the urethra 3:49.

The Hybrid Position

One discussant advocates a combined approach for low fistulas: laparoscopy with modified PSARP keeping the sphincter intact 4:39. This addresses the difficulty of closing the fistula laparoscopically — remnants could cause postoperative diverticulum 4:39. Another frames this as "laparoscopic-assisted PSARP," starting with laparoscopy to mobilize the distal rectum and ligate the fistula, then lifting the legs over the baby's head and making a posterior sagittal incision without returning to prone position 17:20. The posterior sagittal incision is the safe way to get into the perineum; making a tiny anal incision creates a more dangerous operation 17:42. Most injuries have occurred because of blind maneuvers to get into the pelvis 17:52.

Where They Agree

All discussants agree on several fundamental points. Surgical goals are to find the distal rectum, manage the fistula, avoid leaving distal rectum behind, mobilize the rectum with good blood supply, and place it within the sphincter mechanism 0:22. The patient's prognosis is based on the malformation type, spine quality, and sacrum quality regardless of surgical approach, provided the operation is done well with adequate rectal mobilization, fistula disconnection, and no retained distal rectum 14:59.

When discussing cases, the fistula type (bladder neck, prostatic, or bulbar), sacral quality, and spinal quality must be documented to allow meaningful comparison of results 14:38. Literature comparing PSARP to laparoscopy almost never comments on the exact malformation type or the status of the spine or sacrum 0:46, making meaningful comparison impossible 1:01.

The sphincters do not cross the midline; if the surgeon stays perfectly in the midline and reconstructs them, they work 18:20. Patients who had vestibular repairs and trans-anorectal approaches with completely split and reconstructed posterior sagittal incisions remain perfectly continent 18:28.

What Would Resolve It

The discussants did not specify what evidence would settle this question. The disagreement appears to rest on individual surgical experience, complication patterns in referred cases, and technical confidence with each approach rather than on comparative trial data that controls for malformation type, sacral quality, and spinal anatomy.

Takeaways from this story

Bulbar fistula outcomes depend more on malformation anatomy and sacral quality than surgical approach when technique is sound
Anal stenosis occurred in one-third of laparoscopic cases in one series, requiring anoplasty for cutaneous junction narrowing
Posterior urethral diverticula with retained metallic staples represent a recognized complication pattern in referred laparoscopic cases
Laparoscopic-assisted PSARP combines transabdominal mobilization with posterior sagittal access to avoid blind pelvic maneuvers

Anatomic Precision Over Technique Preference in Anorectal Malformation Repair

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

Surgical Goals Trump Technique Selection

The fundamental objectives in anorectal malformation repair—finding the distal rectum, managing the fistula completely, avoiding retained distal rectum, mobilizing the rectum with intact blood supply, and placing it within the sphincter mechanism—matter more than whether PSARP or laparoscopy is used 0:22. The technique should serve these goals, not the reverse. When comparing outcomes, prognosis depends on the underlying malformation type, sacral quality, and spinal status regardless of surgical approach, provided the operation achieves adequate rectal mobilization, complete fistula disconnection, and no retained distal rectum 14:59.

Anatomic Documentation Enables Meaningful Comparison

Literature comparing PSARP to laparoscopy almost never comments on the exact malformation type or the status of the spine or sacrum 0:46. Without knowing the exact anatomy and the status of the sacrum and spine, you cannot make judgments about the prognosis of a patient 1:01. When discussing cases, the fistula type (bladder neck, prostatic, or bulbar), sacral quality, and spinal quality must be documented to allow meaningful comparison of results 14:38. The archaic classification into high, intermediate, and low should not be used when discussing anorectal malformations 9:12. Evaluation must include the quality of the sacrum and whether the patient has tethered cord when comparing results 9:36.

Rectal Position Dictates Approach More Than Fistula Location

When the rectum is very low and bulging, it is very difficult transabdominally to dissect the distal rectum elegantly, mobilize enough rectum, and avoid urethral injury, whereas posterior sagittal provides beautiful exposure 13:48. A high rectum is easier to access transabdominally and laparoscopy is the perfect route for that anatomy 14:15. Smaller rectums with prostatic fistulas are easier to dissect and free from the urethra laparoscopically 12:06, while larger rectums are easier to access from below via PSARP 12:26. The same fistula type may require different approaches based on rectal position.

Technique-Specific Considerations Shape Selection

Bladder neck fistulas are approached with laparoscopy as it is a nice easy way of doing it 2:16. In one series, bulbar fistulas are no longer approached laparoscopically because the benefits do not justify the longer operative time compared to PSARP 1:51, which takes approximately one and a half hours with minimal pain, same-day oral intake, and 48-hour discharge with excellent results 10:56. Bulbar fistulas are more easily approached from below because they are very close and do not require a laparoscope 12:51. Some prostatic fistulas that appear accessible on distal colostogram may be more accessible laparoscopically than from below 10:12.

Laparoscopic-Assisted PSARP Combines Advantages

Laparoscopy is combined with a small PSARP incision (mini PSARP) to place the rectum exactly in the sphincter and muscle complex 13:10. In laparoscopic-assisted PSARP, the procedure starts with laparoscopy to mobilize the distal rectum and ligate the fistula, then the legs are lifted over the baby's head (not returning to prone position) and a posterior sagittal incision is made 17:20. The posterior sagittal incision is the safe way to get into the perineum; making a tiny anal incision creates a more dangerous operation 17:42. Most injuries have occurred because of blind maneuvers to get into the pelvis 17:52.

The Midline Posterior Sagittal Incision Does Not Damage Continence

The sphincters do not cross the midline; if the surgeon stays perfectly in the midline and reconstructs them, they work 18:20. Patients who had vestibular repairs and trans-anorectal approaches with completely split and reconstructed posterior sagittal incisions remain perfectly continent 18:28. The posterior sagittal incision allows tacking the rectum to the posterior edge of the muscle complex, which helps avoid prolapse 18:43.

Laparoscopic Complications Require Vigilance

Anal stenosis at the cutaneous junction level occurred in approximately one in three laparoscopic patients in one series, requiring anoplasty 2:40. Long dissection line and ischemic changes may have contributed to anal stenosis in laparoscopic cases 2:59, as did poor follow-up and inadequate dilatation programs 3:08. Patients referred after laparoscopic repair of bulbar fistulas have presented with huge posterior urethral diverticula and metallic staples in the pelvis with associated complications 11:14.

Takeaways from this story

Document fistula type, sacral quality, and spinal status when comparing outcomes—prognosis depends on anatomy, not technique choice.
A low bulging rectum is difficult to dissect transabdominally; a high rectum is easier laparoscopically—rectal position matters more than fistula location.
Midline posterior sagittal incision does not damage continence when performed correctly—sphincters do not cross the midline.
Laparoscopic-assisted PSARP combines advantages: mobilize laparoscopically, then use posterior sagittal incision for safe perineal access and rectal tacking.
Anal stenosis occurred in one-third of laparoscopic cases in one series, linked to long dissection, ischemia, and inadequate dilation programs.

Choosing Between Laparoscopy and PSARP for Anorectal Malformations Based on Anatomy

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Teaching arc · AI-written, human-reviewed

Surgical goals supersede technique selection

The debate between laparoscopy and posterior sagittal anorectoplasty (PSARP) for anorectal malformations often misses the fundamental point: the surgical goals matter more than the approach 0:22. Finding the distal rectum, managing the fistula completely, avoiding retained distal rectal segments, mobilizing the rectum with intact blood supply, and placing it within the sphincter mechanism — these objectives must be achieved regardless of technique. The operation succeeds or fails based on whether these goals are met, not on which incision was used.

Anatomic documentation enables meaningful outcome comparison

When comparing surgical results, the malformation type (bladder neck, prostatic, or bulbar fistula), sacral quality, and spinal status must be documented 14:38. Without this information, outcome comparisons are invalid 1:01. The archaic classification into high, intermediate, and low malformations should be abandoned 9:12. Patient prognosis depends on the underlying anatomy and the quality of the sacrum and spine, regardless of surgical approach, provided the operation achieves adequate rectal mobilization, complete fistula disconnection, and no retained distal rectum 14:59.

Rectal position, not just fistula location, guides approach selection

A low, bulging rectum presents a different technical challenge than a high rectum, even when the fistula type is identical 13:48. When the rectum is very low and bulging, transabdominal dissection of the distal rectum is difficult, mobilization is limited, and urethral injury risk is high, whereas posterior sagittal exposure is ideal 13:48. Conversely, a high rectum is easily accessed transabdominally, making laparoscopy the perfect route 14:15. Smaller rectums with prostatic fistulas are easier to dissect and free from the urethra laparoscopically 12:06, while larger rectums are more accessible from below via PSARP 12:26. Bulbar fistulas are generally more easily approached from below because they are very close and do not require a laparoscope 12:51.

Catheter-guided dissection minimizes urethral injury

During laparoscopic dissection, placing a catheter from the rectal side of the fistula orifice into the urethra allows measurement of residual fistula length and guides progressive dissection until the fistula is divided approximately 5 millimeters from the urethra 3:49. This technique provides real-time feedback about proximity to the urethra. For rectal bulbar fistulas approached laparoscopically, grasping the distal rectum makes the fistula become shallow and accessible from the abdominal cavity, allowing dissection of the mucosa while leaving the muscular cuff intact to avoid nerve damage 5:56. If the mucosa is resected completely to the most distal part of the rectum, urethral fistula rarely occurs after laparoscopic operation even without ligation or suturing of the fistula 6:58.

The posterior sagittal incision does not damage continence

The sphincters do not cross the midline; if the surgeon stays perfectly in the midline and reconstructs them, they work 18:20. Patients who had vestibular repairs and trans-anorectal approaches with completely split and reconstructed posterior sagittal incisions remain perfectly continent 18:28. The posterior sagittal incision allows tacking the rectum to the posterior edge of the muscle complex, which helps avoid prolapse 18:43. Most injuries occur because of blind maneuvers to get into the pelvis 17:52. Making a tiny anal incision creates a more dangerous operation 17:42.

Laparoscopic-assisted PSARP combines the advantages of both techniques

In laparoscopic-assisted PSARP, the procedure starts with laparoscopy to mobilize the distal rectum and ligate the fistula, then the legs are lifted over the baby's head (not returning to prone position) and a posterior sagittal incision is made 17:20. This hybrid approach uses laparoscopy for mobilization and fistula management while preserving the safe perineal access and precise sphincter placement that the posterior sagittal incision provides. The posterior sagittal incision is the safe way to get into the perineum 17:42.

Bulbar fistula repair via PSARP offers efficiency without compromise

Bulbar fistula repair via PSARP takes approximately one and a half hours with minimal pain, same-day oral intake, and 48-hour discharge with excellent results 10:56. In one series, bulbar fistulas are no longer approached laparoscopically because the benefits do not justify the longer operative time compared to PSARP. Patients referred after laparoscopic repair of bulbar fistulas have presented with huge posterior urethral diverticula and metallic staples in the pelvis with associated complications 11:14. The advantage of laparoscopy is avoiding laparotomy and the associated pain 9:55, but this advantage does not apply when PSARP already provides excellent exposure without laparotomy.

Takeaways from this story

Rectal position, not just fistula type, determines optimal approach: low bulging rectums favor PSARP, high rectums favor laparoscopy.
Outcome comparisons require documenting fistula type, sacral quality, and spinal status — prognosis depends on anatomy, not technique.
Laparoscopic-assisted PSARP combines mobilization advantages with safe perineal access; the midline posterior sagittal incision preserves continence.
Catheter-guided dissection from rectal fistula orifice into urethra allows safe division approximately 5mm from urethra during laparoscopy.
Bulbar fistula PSARP achieves excellent results in approximately one and a half hours with minimal pain and 48-hour discharge; laparoscopic complications include urethral diverticula.

Keywords

anorectal malformations bladder neck fistula prostatic fistula bulbar fistula anal stenosis posterior urethral diverticulum tethered cord vestibular malformation PSARP (posterior sagittal anorectoplasty) laparoscopy laparoscopic-assisted PSARP anoplasty robotic surgery trans-anorectal approach distal colostogram

Hashtags

#PSARP #Laparoscopy #Surgery #AnorectalMalformations #FistulaRepair #MinimallyInvasive #SurgicalTechniques #Urology #PediatricSurgery #SurgicalOutcomes #SurgicalComplications #RectalSurgery #PatientCare #SurgicalInstruments #ProstaticFistula #BulbarFistula #BladderNeckFistula #AnalStenosis #SurgicalEducation #MedicalResearch #AnorectalMalformation #LaparoscopicSurgery #ColorectalSurgery

Transcript

I want to talk a little bit about, uh, the controversial subject of PSARP versus laparoscopy. Um, and, um, I just want to say that I don't understand this argument very well because many of the papers that are written compare the PSARP to laparoscopy. My impression is that our goals are to find the distal rectum. Take care of the fistula, not leave distal rectum behind. Mobilize the rectum with good blood supply and place it within the sphincter mechanism. And however you'd like to achieve that, PSARP laparoscopically doesn't matter as long as those goals are achieved. The, the articles that you will read in the literature that compare PSARP to laparoscopy almost never comment on exactly what the malformation was and what was wrong with the spine or the sacrum. And I think without knowing the exact anatomy and the status of the sacrum and the spine, you cannot make any judgments about the prognosis of a patient. So let's begin this discussion. We have three distal cholostrograms on your screen. And um I guess we could pose this as a question. I'm very curious to know how. Would be handled. Would you do PSARP or laparoscopy in the three types of malformations? Maybe we can go to ALP. Yeah, thank you very much, Mark. I mean, we've just published our experience with laparoscopy on 24 patients and I have to say I have used laparoscopy on all these conditions. Um, the bulbar fistula ones, prosthetic ones, and the bladder neck ones. Our, um, management has changed after the 1st 24 cases. We would not use it for the bulbar fistulas anymore. Um, it can be done technically, it's more challenging, of course, uh, but the benefits of using laparoscopy and spending longer time in theater, um, probably is not there compared to the PA. Um, looking at these pictures, with our experience that we've had so far, um, on the right-hand side, the more bladder neck fistulas, we would approach them with laparoscopy, certainly. It's a nice easy way of doing it. Um, but when it comes to the sort of more on the spectrum of bulbar ones which we're seeing on the left-hand side here, um, we would do them with a piece of. Our experience with laparoscopy, um, in the sort of mid to long term results, the early results, uh, the anal stenosis has been a problem. Um, about 1 in 3 patients we've had anal stenosis at the cutaneous junction level, which required an anoplasty. Um, obviously the, uh, um, long dissection line may have played a role with this. Ischemic changes may have played a role with this. But also our follow-up hasn't been so good and the dilatation programs hasn't been so good. That's what we've established from our little study of 24 cases. Let's hear, uh, uh, Yama. How would you handle these, how would you handle these three cases? I think on the right side, I, I think, uh, prostatic urethra fistula, and I do laparoscopic, uh, treatment in the middle. I think, uh, probably, uh, no fistula, but I do laparoscopically on the left. I think they're very low, they're kind of, uh, r above the fistula, but I do laparoscopically even on the left. And uh uh during dissection I do dissect as much as possible digitally then I put a catheter. From the rectal side of the orifice into the urethra. Another surgeon is watching the, you know, tip of the catheter coming out to the fistula. Then we can measure the residual length of the fistula, so we can continue dissection deeply. Then we can measure the residual fistula again until, you know, we divide the fistula just. Uh, maybe 5 millimeter, uh, on the urethra. That is, uh, what I'm doing now. Uh, OK, when? Uh, yes, for right on versicon fitula, I mean Latin neck. I prefer laparoscopic, uh, right on, right on punctu for lower fitula, I prefer combined between laparoscopic approach and modified PE, keeping the sphincter intact. Because for low feed it's not difficult to dissect fed, but difficult to close the fitula and we could leave some remnant and could cause the diverticulum after the operation. That is why combined with the modified keeping er so far we performed those successful. Uh, very good, and, uh, Longley? Uh, my technique is similar to Professor Yama, uh, only for the high type of, uh, rectal fistula. It's a good opportunity, a good option to take the laparoscopic approach for the, uh, rectal bulbar fistula at the beginning this was considered a contraindication for lap. But with the experience accumulated in our center for this type, I mean the low fistula, they also take the laparoscopic approach our technique is just with the grasper to the distal part of the rectum and then the fistula will become shallow, I mean out from the pelvic floor. Uh, to the, uh, abdominal cavity and then we dissect the mucosa of the fuscular, uh, left the muscular cuff intact to avoid the damage of the nerve. Nerves and the surrounding tissues and in the urethra, in some cases they close the fistula by filtering the muscular cuff. Uh, is, in some very difficult cases, uh, if you resecting the mucosa completely to the most distal part of the rectum, even though without ligation or filtering, the fistula, the, the urethral fuss rarely occurred after the operation by laparoscopic approach. So in our center nowadays, all these three circumstances are indicated for laparoscopic approach. Now with the comparable result. To the posterior sed approach, so we think the laparoscopic approach is very nice with the advantage for the anorectoplasty for high and intermediate. anorectal malformations. OK. OK, um You know, that, um, uh, a very common saying is, uh, there are, there are many ways to skin a cat, and there are many ways to go to Rome. And, um, and, and I encourage all the, all the laparoscopists to continue trying to improve those techniques and moving forward, because what is coming is going to be even better in terms of minimally invasive surgery in the future, and I look forward to see refined instruments with, uh, we already have an excellent view in the laparoscopic field, but the, the instruments, Are currently used from my point of view, the very personal point of view, are still grotesque and rude, but I'm sure that it's coming from a refined instrument that would allow us to reproduce everything that we do under direct vision laparoscopically. That time is coming. Now, having said that, the, um, for all those that are doing laparoscopy, and I happen to review most of the papers that you all guys write. I suggest you, I strongly suggest that when you talk about anorectal malformations, number one, don't keep using the archaic, misleading classification into high, intermediate, and low, or it's like dividing the human beings into bad ones and good ones, or tall, tall ones and short guns, short ones. That's, That's, that's no longer useful for any purpose. Number two, including in your evaluation the quality of the sacrum and whether or not the patient has tested when you compare or try to compare results. Otherwise, don't bother sending those papers because I will be very critical about that until I, until I, I, every, every time I read them. And then, uh, of course, the, the, somebody was asking what's the advantage of laparoscopy. The advantage is try to avoid the laparotomy and the pain related with the laparotomy. So that's why we are very much enthusiastic about laparoscopy in all those patients that need laparotomy. And, and also at our institution, Mark Levitt and I have been there also in patients with, um, Prostatic fistula that we can see in the digital cholestergram like this, we can see that, and that even when some patients have a, a prostatic fistula, that prostatic fistula seems to be more accessible laparoscopically than from below, and we encourage to do it that way. So prostatic fistula, I would say it depends on how, how far, Argue with the laparoscopy. If you feel confident and familiar, go ahead and do it. For bulbar fistulas, we are against, against the use of laparoscopy and for the following reasons. Number one, because it takes us about an hour and a half to repair that malformation. Number two, because they have minimal pain. Number 3, because they eat the same day of surgery, and then because they are discharged 48 hours later, and we can discharge them earlier and because we have excellent. And finally, because we have a series of patients that we receive from surgeons who use laparoscopy in those patients and they refer the patients to us with a huge posterior urethral diverticulum and metallic staples in the pelvis with all the complications that you can imagine about that. And, and that was unnecessary. For those reasons, we believe, but if, but if you feel confident and you follow your patients and you have good results, keep doing it. Let's, uh, let's pull the group on this next slide. I specifically found these two very similar fistulas, but very different rectums. And let's put up laparoscopy, uh, would someone use laparoscopy on the left and on the right? Maybe we can hear from Evo. Uh, these are interesting cases. I, if I look carefully, I think they're both, um, seem to be prosthetic fistulas, and one has, uh, the, what you say on the left side is the smaller fistula, smaller rectum with laparoscopy, it's easier to dissect and to freeze from the urethra. On the right side, you have a larger rectum, and I think for me, uh, I would prefer, I'd probably prefer to do a PSA, um, because it's easier, you can see on the x-ray, it's easier to access, uh, accessible from below, and that's, that's also the reason why I don't see, Any advantages in, uh, in doing a bulbar in laparoscopically, because it's more difficult. It's, it's probably more easier to do it from below, because it's, it's very close, and you don't need a laparoscope to, to get there. And with the smaller fistulas, especially the bladder neck and the prosthetics with a smaller fistula, I think those are the ones you could use laparoscopy. And another thing I'd like to add to it is that, uh, um, and you said it in the beginning, it is, uh, it's not only, uh, PSAP or laparoscopy, but it is, it's PSAP or laparoscopy with a small PSA, because the end phase of your surgery, I, I do not just put it through, but I also make a small incision to do a, a mini PSA to place it exactly in the sphincter, in the muscle complex. So that would be my command to it. Um, let's hear a little bit more about some of the problems that we've seen, uh, from laparoscopy. I think, uh, uh, the reason why these slides, I think, are so instructive and to agree with Evo, when the rectum is very low and bulging, it's very difficult transabdominally to dissect elegantly the distal rectum. Get enough rectum mobilized and not hurt the urethra, whereas posterior sagiti is the exposure to that problem is beautiful. As opposed to the rectum on the left side, which I think is easier to access transabdominally. And laparoscopy is the perfect route for that. Um, um, and you can easily separate the distal rectum. So, in both of these cases, the fistula is very similar, but the rectum are very, is very different. And I think, um, to, um, agree very much with Doctor Pena's point, whenever we talk about these cases, we must say bladder, neck, prostatic or bulbar. We must know the quality of the sacrum, and we must know the quality of the spine, and only then can we compare our results. The reality is that the patient's prognosis is based on what malformation they have and how is their spine and sacrum. No matter how you do the operation, if you do it well and mobilize the rectum well and disconnect the fistula and not leave rectum behind, That gives you the anatomic reconstruction. The results are based on an excellent anatomic reconstruction and the underlying condition of the patient. Um, somebody asked a question mark about robotic surgery. Some think that clear to us about robotics, and I like that question. Let me tell you why I like that. Yes, there are some, there's a recent publication on robotic surgery, one case from an Arab country. They don't give much detail, but I don't know how many of you have had the opportunity to look and play with the robot, and it's really a fantastic view. Not only is it a fantastic view, it's three dimensional, and also you can reproduce. The movements of your, of your hands and all the instruments that we use, uh, in an open surgery, in a, in a robot. And, uh, so it's because all the instruments are digital, so you can make the finest movements that you always dream about. So the future of laparoscopy, I think, is going to be to make the instruments, digital instruments, so we can move inside, and, and, and do beautiful operations very quick and very safe. When I see esophageal attrition repaired thoracoscopically, the image of the fistula and the atticus vein is there, and you feel like walking in and fixing that beautifully. You, you, we basically drool when they decide to go there and repair it because the view is so exciting, but then suddenly you see this monster instrument getting there with movements like that and pulling and pushing and and. Big needle moving like that and I still don't like that, but no question that the, the merge of the technology used for robotic with the with the principles of laparoscopic is with the future and you will be seeing it and doing it. I hope to be part of that. Yeah, and I would also just say that someone asked about whether to use the PSARP. What I would suggest is do the laparoscopy with the PSARP. Don't lose the advantage of the PSARP incision. You don't need as long of a PSARP incision when you do it laparoscopically. What we will do is start with laparoscopy, mo, Mobilize the distal rectum, ligate the fistula, gain adequate length, lift the legs over the baby's head. We don't go back to prone. We don't need prone in this circumstance. Make a posterior sagittal incision. That is the safe way to get into the perineum. There's no reason to make a tiny anal incision. You're just making it a more dangerous, Dangerous operation, and most of the injuries that we've seen have been because there's a blind maneuver to get into the pelvis. So take advantage of the posterior sagittal incision. There's no, nothing bad about the posterior sagittal incision. People talk about you're cutting the sphincter. That is old school. That is not true. We have hundreds of patients who had a, Uh, midline posterior sagittal incision. The sphincters are not cut. Doctor Pena proved to us that the sphincters don't cross the midline. And if you stay perfectly in the midline and reconstruct them, they work. We have patients, many patients, vestibulars. We have patients who've had a trans anorectal approach to problems in the urethra. The posterior sagittal incision is completely split, reconstructed, and the patient remains perfectly continent. So the advantage of the posterior sagittal incision is you help yourself get into the pelvis, you pull on the rectum, and then you can tack the rectum, Two, the posterior edge of the muscle complex, which helps to avoid, uh, prolapse. So what we would suggest is a laparoscopic assisted PSARP, and I would advocate a new terminology, laparoscopic assisted PSARP, because take advantage of the laparoscopy and take advantage of the PSARP. Want to wind it down? Yeah, I, well, talk about perfect. Uh, Well that was I would say we've been doing this for 4 years now I think that was probably the best discussion we've ever had.

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