Colorectal Quiz: August 28, 2023

Ron Reeder • August 28, 2023

Quiz for August 21:

A baby girl with ARM and rectovestibular fistula is taken to the OR for planned PSARP. Careful inspection reveal at first a normal appearing introitus and hymen, but probing shows that in fact she has distal vaginal atresia. What would you do in this case? Some potential options are below.

a. Cancel the procedure and come back another day

b. Proceed with PSARP and leave the vagina for another day

c. Proceed with PSARP and perform laparoscopy to determine the Mullerian anatomy

d. Proceed with PSARP and perform vaginal replacement using the distal rectum left for neovagina and mobilize a more proximal piece of rectum for the anoplasty

e. Proceed with PSARP using the rectum in the vestibule for rectum and performing a neovagina with sigmoid or small bowel

f. Something not listed above, in such a case I would________________________________.


Answer for August 21st:

This is a fascinating case and reminds us of how important it is to always assess the Mullerian anatomy in any female patient with ARM. We decided to perform the PSARP and to do a diagnostic laparoscopy. (Choice C). The laparoscopy revealed an atretic left Mullerian system with normal ovary, and what appeared to be a unicornuate uterus on the right with potentially a blind ending distal vagina in the pelvis. To continue this case, the next quiz is – what would you do now?


Quiz for August 28th:

Based on last week’s quiz, a baby girl with ARM and rectovestibular fistula who was taken to the OR for a PSARP and found to have distal vaginal atresia – with laparoscopy performed showing an atretic left Mullerian system with normal ovary, and what appeared to be a unicornuate uterus on the right with potentially a blind ending distal vagina in the pelvis. What would you do now? 

A. PSARP only, leave the Mullerian system untouched

B. PSARP plus vaginal replacement using the distal rectum

C. PSARP plus vaginal replacement using sigmoid, keep the distal rectum as rectum

D. Pull-through of native left vagina to perineum

E. Something not listed above, I would do___________________________.

How would you handle this case?

Colorectal Conundrum: January 29, 2024

By Ron Reeder • January 29, 2024
Colorectal Conundrum for January 29: A male with a rectoperineal fistula undergoes a PSARP with mobilization of the rectum, both anterior and posterior rectal walls. In the days following surgery he starts to drain urine around the anoplasty consistent with a urethral injury. He is also voiding via the penis. A cystogram is shown below. How would you manage this situation? Answer: This patient has suffered from a urethral injury, and urine is draining out the posterior urethra into the perineum around the anoplasty. The key first step is to divert the urine with a suprapubic tube. A colostomy is not necessarily needed. The fistula might heal with diversion. If after a month or so a cystogram shows the persistence of the fistula, then a redo is needed with re-mobilization of the rectum, fully lifting the anterior rectal wall off of the urinary tract, and repair the urethra, with coverage of the posterior urethra with an ischiorectal fat pad. Then a voiding trial a month later with ultimate removal of the SP tube.

Colorectal Conundrum: January 22, 2024

By Ron Reeder • January 22, 2024
Colorectal Conundrum for January 22nd: In the previous week’s case, of an imperforate hymen, the MRI showed dilation all the way down to the perineum. Management involved a perineal – introital – incision to drain the fluid. If that were not the case and you had a dilated vagina but the distal extent was far away from the introital area, how might you handle that hydrocolpos? Answer: If this were a case of hydrolpos with normal anus and normal urethra, and the vagina cannot be drained by the introitus like an imperforate hymen, then drainage needs to be from above. IR or laparoscopy is an ideal approach to get a drain in the dilated structure (remember this could be bilateral, so both sides may need to be drained. Drainage is to relieve distension and most concerning its potential cause of distal ureteral obstruction causing hydronephrosis. Once the material hormones have dissipated the hydrocolpos will resolve and can be dealt with later in life via a laparoscopic distal vaginal pull-through, after the onset of puberty. In such a patient, I would follow closely with ultrasound 6 months after thelarche (breast budding).

Colorectal Conundrum: January 16, 2024

By Ron Reeder • January 16, 2024
Colorectal Conundrum for January 16: A newborn female is noted to have abdominal distension. On exam the uretha and anus are normal, and there appears to be a bulge in the hymen. The has an MRI with the image shown below. What would be your treatment plan? What are the variations in such a case and how would you manage each? Answer: This could be a case of imperforate hymen, but the MRI is key – how high up is the obstruction? How large is the hydrocolpos? In this case, it appears that a perineal incision might all that is needed as the dilation extends all the way down to the perineum. That is the most common scenario. An incision at the level of the hymen should drain out the fluid and no further intervention should be needed. Of course a careful exam needs to check to be certain you see a urethra – sometimes such a bulge could be a paraurethral cyst. For the next week’s question – what would you do if the perineal approach was inadequate – i.e. could not reach the dilated lumen.
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