Posterior Rectal Advancement Anoplasty (PRAA) in a male with an anorectal malformation and rectoperineal fistula
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 males with anorectal malformation and rectoperineal fistula, the good rectal lumen is only millimeters below the anal skin where the anoplasty needs to be.
The ellipse of tissue visible on examination represents the anal sphincter.
In males with rectoperineal fistula, the fistula opening is located in the anterior portion of the sphincteric ellipse, but most importantly it is within the ellipse.
Urethral injury can result from inadvertent opening of the urethra during an operation for a male with a rectal perineal fistula, a complication that is surprisingly easy to do.
The urethra is very close to the rectal wall in males with rectoperineal fistula.
The traditional approach to rectoperineal fistula had been a standard posterior sagittal anorectoplasty (PARP) with full thickness circumferential mobilization of the rectum.
The traditional PARP technique can lead to urethral injury.
With posterior rectal advancement anoplasty (PRAA), no dissection at all is done for the anterior rectal wall.
In males with rectoperineal fistula, the fistula location at the anteriormost part of the sphincter can always be found.
Sometimes the fistula runs in a subepithelial plane into the scrotal raphae, but the key location to identify is the opening at the anteriormost part of the sphincter.
Right below the surface of the fistula opening at the anteriormost part of the sphincter is where the rectal lumen lies.
The midline incision for PRAA should not go any farther posterior than the intended anoplasty, which avoids having any posterior sagittal incision to close or to heal.
In PRAA, only the skin of the two triangles created by the midline incision is removed, preserving the muscle fibers below.
In PRAA, the anterior rectal wall is not touched, which prevents any potential injury to the urethra, previously the most feared complication of this operation.
The PRAA technique preserves the dentate line in the anal canal.