The posterior sagittal approach for recurrent genitourinary pathology

The posterior sagittal transanorectal approach offers the surgeon excellent exposure to the lower genitourinary system. The approach has been successfully used for revisional surgery involving the urinary tract and rectum. We have used this approach to treat müllerian remnants, acquired or congenital fistulas and acquired urethral strictures. In the setting of revisional surgery abdominal or perineal approaches may not provide the same level of exposure to the lower urinary tract.

Of 911 males who underwent a posterior sagittal approach 12 were identified in whom this approach was used to manage lower urinary tract problems without associated anorectal malformation (group 1). An additional 58 patients with associated anorectal malformations were included in analysis (group 2).

All cases were approached with a posterior sagittal incision to facilitate exposure after failed prior surgical attempts to treat traumatic strictures of the proximal urethra in 4 and müllerian remnants in 8 (group 1). In group 2 there were 19 urethral diverticula, 8 strictures and 31 persistent rectourethral fistulas. Followup was 6 months to 15 years. There were no recurrences identified in group 1. In group 2 there were 5 postoperative urethrocutaneous fistulas. Data on potency were available on 4 patients in group 1 and 14 in group 2. All 14 patients in group 2 reported intact potency after surgery. One patient in group 1 was impotent before and after surgery.

The posterior sagittal approach is helpful for addressing lower urinary tract pathology when exposure is inadequate from a perineal or abdominal approach. We propose that better exposure with this approach may limit inadvertent injury to nerves and result in more complete treatment of the presenting pathological condition. This approach provides an alternative that warrants careful consideration when dealing with the lower genitourinary tract in pediatric patients, especially in the setting of revisional surgery.