Department of Pediatric Urology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, United States.
Urethral-enteric fistulae with hypoplastic/atretic distal urethra in boys with anorectal malformations are amenable to management via sequential dilation of the distal urethra (P.A.D.U.A.) and subsequent repair of the fistula, but failure of this technique occasionally requires complex reconstruction. We present a novel surgical approach, along with long-term results, that incorporates rotation of the amputated fistula tract (RAFT) in boys with H-type urethral-enteric fistulae.
The charts of four patients undergoing the RAFT procedure were reviewed. All had previously failed P.A.D.U.A. Surgical principles were similar in all cases: the fistula tract was amputated as close to the bowel as possible. A tubularized or on-layed urethra was then fashioned from preputial skin and anastomosed to the distal end of the urethral fistula. The distal end of the neourethra was then brought to the tip of the penis, or anastomosed to the proximal end of the patent distal urethra.
Mean age was 12.3 months, and there was a mean follow up of 10.2 years. All four patients had a rectourethral fistula as a component of VACTERL, with a urethral deficit of 7-11 cm. All had a functionally intact urethra on reconstruction, with normal continence and bladder neck closure. Two patients needed further bladder augmentation with a Mitrofanoff channel for poor bladder compliance. Both boys who were post-pubertal in this series report normal sexual function with antegrade ejaculation.
The RAFT technique represents a viable reconstructive option for congenital H-fistulae with distal urethral stenosis, with excellent long-term results. It provides boys with normal urethral function, along with intact urinary continence and antegrade ejaculation. This technique may be of particular utility in patients after failed P.A.D.U.A., or in whom a staged buccal onlay graft is not feasible.
Kaye JD, Srinivasan AK, Koyle MA, Smith EA, Kraft KH, Hanna MK, Kirsch AJ. Are you the author?
Reference: J Pediatr Urol. 2011 Apr 18. Epub ahead of print.