Rectovestibular fistula: Which surgical approach is suitable? A randomized controlled trial

Abstract

The management of a vestibular fistula is a challenge for pediatric surgeons. We compared four different operative techniques in terms of postoperative complications, continence, and cosmetic appearance. This prospective, randomized, comparative study included female children with rectovestibular fistulae who were selected from patients with Anorectal Malformations (ARMs) treated between January 2016 and July 2020. The patients were randomly divided into four groups based on the operative technique: Trans-Sphincter Anorectoplasty (TSARP), Posterior Sagittal Anorectoplasty (PSARP), Classic Anterior Sagittal Anorectoplasty (ASARP), and modified ASARP. The incidence of vestibular fistulae among all patients with ARMs was 13.4%. The total number of patients with vestibular fistula was 112, including eighty-four (75%) with rectovestibular fistulae and twenty-eight (25%) with anovestibular fistulae. Associated congenital anomalies were found in nineteen (22.6%) patients. The percentage of parents satisfied with the cosmetic appearance and continence of their children was the highest after TSARP. PSARP had the lowest incidence regarding vaginal wall injuries. TSARP is the best operative technique for handling rectovestibular fistulae and is suitable for infants and children. In the TSARP technique, the external sphincter muscle can be preserved following complete dissection of the rectum without the need for a midline skin incision. A midline skin incision is required in the modified ASARP technique.

One Stage Anterior Sagittal Sphincter Saving Anorectoplasty (ASSSARP) for the Repair or Rectovestibular Fistula: Mid and Long-term Outcome in Two Tertiary Centers.

“…With long-term follow-up, constipation improved with age. This observation was also supported by other reports [25,41,49].…”

“…They were all due to poor parent compliance with the postoperative home 10 anal dilatation protocol. Reported rates of anal stricture from 0 to as high as 26% are reported in the literature (25,38,47). Wehrli L. et al, 2022, in a retrospective study, reported a 0 anal stricture in 84 children with different ARMs.…”

“…Obviously, 3 procedures burden the patients and their parents physiologically, psychologically, and economically. Therefore, during the last 3 decades, many pediatric surgeons reported performing a one-stage correction for intermediate and high ARMs in the newborn period, including male defects, without a protective colostomy with satisfactory results [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25]; many reported this policy specifically, in RVF and rectoperineal fistula (RPF) [8, 10, 16, 19 -25, 35-38].…”

“…Muscle complex preservation (no cutting) was described by some authors; both by ASARP or modified PSARP [19,20,39]. Liem N and Quynh T, 2015 thought that preservation of the integrity of the external sphincter could provide better continence and lower rates of constipation as it avoids sphincter scarring [20,25].…”

“…Abdelmohsen S et al found that voluntary bowel control, anocutaneous reflex, and anal squeeze response on rectal examination were better in the TSARP and modified ASARP. They proposed that keeping the sphincter intact in those groups vs division and rejoining the external sphincter muscle in the other techniques, may explain that [25]. The cosmetic appearance also markedly improves with age, and years later, the scar is barely perceived, Fig.…”