Laparoscopic-assisted anorectoplasty allows accurate placement of the rectum within the muscle complex through its radially dilated tract, thereby decreasing the risk of perineal scarring and disruption of external sphincter fibers [4].
Fistula ligation using clips, suture, or endoloop has been the standard technique during PSARP and LAARP [3, 5]. The technique of simple division of the rectourethral fistula has been adapted recently by several pediatric surgeons [5,6,7,8,9].
In majority of the males with rectourethral fistula, the distal rectum lies below the peritoneal reflection. A long common wall between the rectum and urethra usually makes the surgical dissection technically more challenging through the abdominal approach.
The traction applied at the end of the rectum to visualize the fistula causes tenting of the urethra with a potential risk of transfixion of urethra with a stitch [10]. It has been postulated that simple division of the fistula without ligation has a lower risk of injury to the urethra [6].
Urological complications following repair of anorectal malformations include urethral stricture, recurrent fistula, and posterior urethral diverticulum (PUD). Frequency of urological complication is reported to be higher with laparoscopy assisted anorectal pull-through (LAARP), especially with cases of rectobulbar fistula [11, 12]. PUD in particular, occurred more often in cases where the fistula was ligated through a transabdominal approach [8].
Posterior urethral diverticulum develops from a retained portion of the rectourethral fistula, which inflates as urine is collected in the pouch-like structure [8]. It can also form if the fistula is not divided flush, which can be technically challenging with the use of laparoscopic instruments in case of a bulky rectum, a wide base of a rectourethral fistula, and awkward angles during the placement of sutures [13].
In 2008, Rollins et al. [6] described his experience with five patients who underwent LAARP with simple division of the fistula. Although he reported one patient with PUD, this was attributed to not dividing the fistula flushed with the urethra as confirmed with intraoperative photographs.
In a series of 68 patients reported by Sudhakar et al., he compared the outcome of 34 patients wherein the fistulas were ligated during PSARP, and 34 patients without closure of fistulas. Closure of rectourethral fistulas resulted in urological complications in 11.8%. Those complications included urethral stenosis, urethral diverticulum, and neurogenic dysfunction.
On the other hand, the non-closure group had an uneventful recovery with their post-operative micturating cystourethrogram (MCUG) and urethrocystoscopy showed normal urethra, without stenosis or stricture, urethro-ejaculatory duct/vasal reflux, or diverticulum in any of the cases [7].
Another series of 24 cases of males having ARM that were managed with simple division of the fistula during PSARP (22) and LAARP (2) showed no evidence of postoperative urine leak and showed normal MCUG during the 1-year follow-up. The author suggested that this technique might decrease the risk of urethral diverticulum formation [8].
In our institution, the laparoscopic approach for ARM has been widely used for the past 15 years. All patients in this series had the fistula divided with a simple scissor or hook without ligation, which made the operation technically quicker and less demanding.
Most patients have completed 2 years of follow-ups, while some follow-ups extended up to 10 years with no immediate or long-term urological complications.
Our protocol is to request an MCUG only if the patient develops active urinary complaints. Among them, one patient developed a urethral diverticulum. However, this patient is a known case of megaurethra and distal hypospadias with complicated postoperative course including urethral stricture. The stricture was identified during the pull through procedure. A diverticulum was detected from the MCUG performed after repeated urinary tract infections. We believe that the cause of diverticulum in this case is related to his pre-existing urological complications.
