Anorectal malformation with rectoperineal fistula in males treated with a posterior rectal advancement anoplasty (PRAA) - report of early outcomes.

Abstract

Aim: A novel modification of the cutback procedure, a posterior rectal advancement anoplasty (PRAA) for select male patients with an anorectal malformation and a rectoperineal fistula was recently described which incised only within the limits of the sphincteric ellipse and eliminated an anterior rectal dissection, thus avoiding any possibility of a urethral injury. This report provides longer term postoperative outcomes after PRAA. Method A retrospective, single institution study was performed examining male patients with a rectoperineal fistula between 1/2020-12/2023. PRAA was done only if the rectoperineal fistula was located within the anterior extent of the sphincteric ellipse, which was true for all patients encountered during this study period. We assessed post-operative outcomes, length of stay, time to first feeding, and early stooling patterns. Results Eighteen patients underwent PRAA at a median age of 5.4 months (range 1 day-8 months) with median follow up of fourteen months (range 4-40). Seven patients (39%) were repaired within the first month of life. Thirteen (72%) were repaired primarily and five (28%) had a diverting ostomy placed before referral. There were no instances of wound dehiscence, rectal prolapse, or urethral injury. Two (11%) patients developed an anal stricture requiring dilation or Heineke-Mikulicz anoplasty. All patients resumed feeds on post operative day one. Median discharge was on post operative day one (range 1-6). Fifteen (83%) were utilizing laxatives at their most recent follow up. Conclusions The PRAA avoids any potential urethral injury or perineal dehiscence, has a low rate of anal stenosis (11%), and appears to be applicable to all male patients with a rectoperineal fistula. The technique allows for early return to diet and discharge and can be safely done in the neonatal period or in a delayed fashion without the need for a stoma.