Posterior sagittal approach with perirectal dissection for reconstructive surgery of severe urogenital anomalies

There are many approaches for surgery of complicated congenital and acquired urogenital anomalies in children with intact rectum. Pena advocates the mid-sagittal division of the sphincter mechanism posterior and anterior to the rectum, along with opening of the posterior and anterior rectal walls. The aim of this study is to determine whether the posterior sagittal approach with perirectal dissection (PSAPD) and elevation of the mobilized rectum would impair fecal continence when used for correction of complicated urogenital anomalies in children with normal rectum. Between 1988 and 1994 the authors performed PSAPD in eight infants and children with an intact anorectum. Indications for PSAPD were high vaginal atresia, Mullerian duct remnants, prostatic rhabdomyosarcoma, and traumatic vesicovaginal fistula. After a mean 10-year follow-up the bowel habits were assessed. Anorectal and uromanometric studies and a detailed questionnaire (modified Holschneider's scoring) sent to children or parents were evaluated. Three patients who preoperatively were clinically fecal continent had soiling only at the time of diarrhea. Early postoperative low anorectal pressure profile normalized during the follow-up. Seven patients had a fecal continence score above 23, two of them with maximum points of 26. Only one girl had a low score of 15. The authors conclude the PSAPD which offers a few advantages over the sagittal division of the rectum provides an alternative approach for selected lesions of the genitourinary tract in children with a normal rectum. Our results suggest that fecal continence is either preserved or partially affected.