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Technical Considerations in Primary Repair of a Congenital Prostatic Rectourethral Fistula in an Adult-Sized Patient
Timothy F Tirrell1, Farokh R Demehri1, Prathima Nandivada1
1Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, United States.
Insights
This study details the successful robotic-assisted surgical repair of a rare rectourethral fistula in a 17-year-old male. The combined approach ensured precise dissection and good functional outcomes for this congenital anorectal malformation.
Area of Science:
- Pediatric Surgery
- Urology
- Gastroenterology
Background:
- Congenital anorectal malformations typically require early surgical intervention.
- Delayed diagnosis and repair of rectourethral fistulas present unique surgical challenges in older patients.
Observation:
- A 17-year-old male with an unrepaired congenital rectourethral fistula underwent surgical correction.
- A combined abdominal and perineal approach with robotic assistance was employed for fistula division and pullthrough anoplasty.
Findings:
- Simultaneous cystoscopy and robotic fluorescence confirmed complete fistula dissection, preventing posterior urethral diverticulum formation.
- The procedure was well-tolerated, with excellent anoplasty healing and good fecal and urinary continence at 9 months postoperatively.
Implications:
- Robotic assistance facilitates minimal perineal dissection and precise rectourethral fistula repair in adolescents.
- This approach offers a viable solution for complex, late-presenting congenital anorectal malformations, improving functional outcomes.
Abstract:
Congenital anorectal malformations are generally diagnosed and repaired as a neonate or infant, but repair is sometimes delayed. Considerations for operative repair change as the patient approaches full stature. We recently encountered a 17-year-old male with an unrepaired congenital rectourethral fistula and detail our experience with his repair. We elected to utilize a combined abdominal and perineal approach, with robotic assistance for division of his rectourethral fistula and pullthrough anoplasty. Cystoscopy was used simultaneously to assure full dissection of the fistula and to minimize the risk of leaving a remnant of the original fistula (also known as a posterior urethral diverticulum). The procedure was well tolerated without complications. His anoplasty was evaluated 60 days postoperatively and was well healed without stricture. At 9 months of follow-up, he has good fecal and urinary continence. Robotic assistance in this procedure allowed minimal perineal dissection while ensuring precise rectourethral fistula dissection. The length of the intramural segment of the fistula was longer than anticipated. Simultaneous cystoscopy, in conjunction with the integrated robotic fluorescence system, helped reduce the risk of leaving a remnant of the original fistula.
