Evaluation of the functional outcome of the neonatal one stage posterior sagittal anorectoplasty (PSARP) as a procedure to treat cases of high anorectal malformation in male neonates

Abstract

Ahmed Elrouby, Saber Waheeb, Ahmed Khairi, Omar Fawzi

Background: Male anorectal malformations have many varieties, from simple types that can be easily repaired in one stage to more complex types that need more sophisticated repair in a staged approach. The staged approach has higher morbidity than the one-stage approach and includes colostomy complications, risk of repeated anesthesia and surgery, high cost and psychological burden on parents. Based on these disadvantages of the staged posterior sagittal anorecto-plasty (PSARP) for high anorectal malformations, one-stage neonatal PSARP has been developed. The aim of our work was to evaluate the functional and clinical outcome of the one-stage approach in the treatment of selected cases of male neonates with high anorectal malformationsMaterial and methods: Our retrospective study which included male patients who had neonatal one-stage PSARP for their high anorectal anomalies between 2006 and 2013. Inclusion criteria included patients with flat or mildly distended abdomen; those in whom the cross-table film of the abdomen showed the rectal pouch reaching down to the fifth sacral segment and patients passing meconium from the urethra. However, cases with complete sacral agenesis, major cord anomalies, and a markedly distended abdomen—possibly due to a megarectum—were excluded from the selection. Pa-tients were evaluated for their functional and clinical outcome at the time of the follow-up in January 2018. Patients with poor outcomes were further evaluated by MRI and examination under anesthesia.Results: Our retrospective study included 24 patients with an age range between 5 and 11 years at the time of follow up in January 2018. Sixteen patients had a recto-bulbar fistula, six patients had a recto-prostatic fistula, and only two patients had recto-bladder neck fistula. According to the continence outcome, 15 patients had a good outcome, all of them had a recto-bulbar fistula. Six patients had a fair outcome; 5 of them had a recto-prostatic fistula, and only one patient had a recto-bulbar fistula. The remaining three patients who had poor outcome included all patients with recto-bladder neck fistula (2 patients) and one patient with recto-prostatic fistula; this was statistically significant (P<0.001). MRI and examination under anesthesia for the three patients with poor continence outcome revealed underdeveloped muscle complex and centrally positioned anus in all patients.Conclusion: One stage neonatal PSARP for males with high anomalies needs special surgical experience, and it should be used only in selected cases. It has the advantage of avoiding colostomy complications, the cost of repeated surger-ies and parents’ psychological burden. Recto bladder neck fistula and poor sphincter muscle development are the main causes of poor functional outcome later on.