Reverse Needle Driving via Umbilical Trocar: An Effective Technique for Treating Recto-Bulbar Urethral Fistula in...

Laparoscopically assisted anorectoplasty (LAARP) for recto-bulbar urethral fistula (RBUF) has not become standard practice because of the risk of urethral injury and incomplete fistula removal in the deep pelvic space. We herein report an effective technique for treating recto-bulbar fistula, called "Reverse needle driving via umbilical trocar" in LAARP.

The patient was diagnosed with RUBF by distal colostogram, and LAARP was planned to be performed. A 5-mm trocar was inserted at the umbilicus and three additional trocars were inserted. The surgeon stands on the right side of the patient and performs anorectoplasty. The RUBF was ligated with a trans-fixing suture of 4-0 absorbable monofilament that passed through the fistula tract using reverse needle driving with the surgeon's left hand. Since the surgeon's left-hand forceps are inserted through the umbilical trocar, which is located in the midline, the suture could be reliably placed just below the urethra by performing reverse left needle driving in a straight line through the umbilical trocar, confirmed with a urethroscope. After transection of the fistula, the rectum was pulled through and the stump was sutured to the perineal skin to construct the neo-anus. Postoperative imaging revealed complete fistula closure, without complications.

This technique addresses the traditional challenges of urethral injury risk and incomplete fistula removal by utilizing strategic umbilical trocar positioning combined with flexible urethroscope confirmation. This robust RUBF technique represents an effective and safe approach for treating RUBF in LAARP.