Posterior Rectal Advancement Anoplasty (PRAA) in a male with an anorectal malformation and rectoperineal fistula

Posterior rectal advancement anoplasty, PRAA in a male with an anorectal malformation and rectal perineal fistula. In this video, we show a new approach to males born with an anorectal malformation with a recto perineal fistula. Here you see 4 versions of this type of malformation. In the first panel you see a bucket handle. In the second you see meconium in the midline raphae. In the third panel, the fistula exits high at the upper scrotum, and in the 4th panel, mucus lies in the raphae. In all cases, the good rectal lumen is only millimeters below the anal skin where the anoplasty needs to be. You can also notice, and this is particularly evident in the 4th picture, the ellipse of tissue which represents the anal sphincter. Here there is a dot of mucus. But it's in the anterior portion of the ellipse, but most importantly, it is within the ellipse. Now what do you see here? Would you consider this contrast study an image of a remnant of the original fistula, a urethral injury? A normal study or false passage likely related to a traumatic catheter placement. Well, it is clearly a urethral injury. This resulted from an inadvertent opening of the urethra during an operation for a male with a rectal perineal fistula, a complication that is surprisingly easy to do. And you notice why. Here you see an artistic diagram showing how close the urethra is to the rectal wall. The traditional approach to this malformation had been a standard posterior sagittal anorectoplasty, a Parp, with a full thickness, circumferential mobilization of the rectum. But this technique can lead to this terrible urethral complication. With the development of the PRAA posteriorectal advancement anoplasty, no dissection at all is done for the anterior rectal wall. And here you see the steps of this operation. And the ready to complete anoplasty with the anterior wall not touched. And here you see a photograph of how this looks one month later. And now we begin the operation video. We begin in prone position. First, we mark the sphincteric ellipse. You notice the pink discoloration which represents the sphincter with the muscle fibers beneath showing through as red. You can see that this patient has great sphincteric contractions. The rectal perineal fistula is in the anteriormost portion of the ellipse, and it is vital to note that the fistula is in fact within this ellipse, not outside of it. In males, this location can always be found. Sometimes the fistula runs in a subepithelial plane into the scrotal raphae, but the key location to identify is the opening at the anteriormost part of the sphincter. And right below that surface is where the rectal lumen lies. We are now marking the sphincter with a pen, as well as the fistula. The incision is in the midline without going any farther posterior than the intended anoplasty. This avoids having any posterior sagit incision to close or to heal. We removed just the skin of the two triangles that were created by this midline incision, preserving the muscle fibers below. I am now placing silk sutures, full thickness into the fistula. And here we are setting up for a posterior and lateral dissection of the rectal wall. The anterior wall is not touched. The Lone Star retractor is very helpful to set up this case. I now begin the lateral dissection, keeping this full thickness along the rectal wall. The rectal wall remains intact. Here I am checking if we have done enough mobilization. Will the healthy mucosa easily reach the skin for the anoplasty with no tension? I now split the silks and place each side onto a mosquito. This provides access to incising the fistulous tissue back to the healthy rectal wall. I am pointing out here that the anterior wall was untouched. This prevents any potential injury to the urethra. Previously the most feared complication of this operation. We cut the posterior midline incising the fistula tissue. One stitch at 12 o'clock. I now trim off 1 to 2 millimeters of fistulous tissue on the lateral sides. You will note that this technique actually preserves the dentate line in the anal canal. Now we place a suture at 2 o'clock. And we trim the other side of the fistulous tissue. And a suture at 10 o'clock. And then around the circle to complete the anoplasty.