Abstract
Objective 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 and 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 January 2020 and December 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 postoperative 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 a median follow-up of 14 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 postoperative
day one. Median discharge was on postoperative day one (range 1–6). Fifteen (83%)
were utilizing laxatives at their most recent follow-up.
Conclusion 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.
Level of Evidence Level III.
Keywords
anorectal malformations - perineal fistula - operative technique - posterior sagittal
anorectoplasty
