Pediatric Surgery International

, Volume 35, Issue 2, pp 247–251 | Cite as

Fact or myth? The long shared common wall between the fistula and the urethra in male anorectal malformation with urethral bulbar fistula

  • Hiroyuki KogaEmail author
  • Stephanie Y. Chen
  • Hiroshi Murakami
  • Go Miyano
  • Takanori Ochi
  • Geoffrey J. Lane
  • Philip K. Frykman
  • Atsuyuki Yamataka
Original Article



It has long been considered surgical dogma that the length of the shared common wall (CW) between a fistula and the urethra in males with anorectal malformation (ARM) and rectourethral bulbar fistula (RUBF) is considerably longer than in males with ARM and rectourethral prostatic fistula (RUPF). This belief has led surgeons who perform laparoscopic-assisted anorectoplasty (LAARP) for RUPF to avoid LAARP for RUBF for risk of potential injury to the urethra or incomplete removal of the fistula. In this study, we compared CW between RUBF and RUPF using distal colostography (DCG) and direct intraoperative measurements.


DCG of rectourethral fistula patients (n = 63; RUBF: n = 44; RUPF: n = 19) were used to measure CW retrospectively. Results were expressed as a ratio of the height of L4; i.e., CW:L4. If less than 0.7, the CW was classified as being “short”; if 0.71–1.4, as being “medium”; and if greater than 1.41, as being “long”. CW that could not be measured was classified as indeterminate. 24 of these patients also had CW measured intraoperatively during LAARP as previously described. The results obtained using both techniques were also compared.


Surprisingly, CW:L4 in RUBF patients was short in 47.7%, medium in 27.3%, long in 20.5%, and indeterminate in 4.5% on DCG, equivalent to mean lengths of 7 mm, 8.5 mm, and 10.3 mm obtained using direct intraoperative measurement for short, medium, and long CW:L4 categories, respectively. CW:L4 in RUPF was short in 73.6%, medium in 10.5%, and long in 5.2% on DCG, while mean intraoperative measurements were 5 mm, 7 mm, and 10 mm, respectively. Differences in CW measured intraoperatively were not significantly different between RUBF and RUPF (p = NS).


From our findings, 47.7% of CWs in RUBF were short using two independent methods, with only 20.5% being long. Thus, LAARP should be considered actively for treating selected RUBF cases and not be excluded on the basis of CW length.


Length of common wall Rectourethral bulbar fistula Rectourethral prostatic fistula Anorectal malformation 


  1. 1.
    Georgeson KE, Inge TH, Albanese CT (2000) Laparoscopically assisted anorectal pull-through for high imperforate anus–a new technique. J Pediatr Surg 35(6):927–930 (discussion 30–1) CrossRefPubMedGoogle Scholar
  2. 2.
    deVries PA, Pena A (1982) Posterior sagittal anorectoplasty. J Pediatr Surg 17(5):638–643CrossRefPubMedGoogle Scholar
  3. 3.
    Koga H, Kato Y, Shimotakahara A et al (2010) Intraoperative measurement of rectourethral fistula: prevention of incomplete excision in male patients with high-/intermediate-type imperforate anus. J Pediatr Surg 45(2):397–400CrossRefPubMedGoogle Scholar
  4. 4.
    Jung SM, Lee SK, Seo JM (2013) Experience with laparoscopic-assisted anorectal pull-through in 25 males with anorectal malformation and rectourethral or rectovesical fistulae: postoperative complications and functional results. J Pediatr Surg 48(3):591–596CrossRefPubMedGoogle Scholar
  5. 5.
    Wang C, Diao M, Li L et al (2017) Laparoscopic dissection and division of distal fistula in boys with rectourethral fistula. J Surg Res 211:147–153CrossRefPubMedGoogle Scholar
  6. 6.
    Ichijo C, Kaneyama K, Hayashi Y et al (2008) Midterm postoperative clinicoradiologic analysis of surgery for high/intermediate-type imperforate anus: prospective comparative study between laparoscopy-assisted and posterior sagittal anorectoplasty. J Pediatr Surg 43(1):158–162 (discussion 62–3) CrossRefPubMedGoogle Scholar
  7. 7.
    Koga H, Miyano G, Takahashi T et al (2010) Comparison of anorectal angle and continence after Georgeson and Pena procedures for high/intermediate imperforate anus. J Pediatr Surg 45(12):2394–2397CrossRefPubMedGoogle Scholar
  8. 8.
    Koga H, Ochi T, Okawada M et al (2014) Comparison of outcomes between laparoscopy-assisted and posterior sagittal anorectoplasties for male imperforate anus with recto-bulbar fistula. J Pediatr Surg 49(12):1815–1817CrossRefPubMedGoogle Scholar
  9. 9.
    Yamataka A, Lane GJ, Koga H (2013) Laparoscopy-assisted surgery for male imperforate anus with rectourethral fistula. Pediatr Surg Int 29(10):1007–1011CrossRefPubMedGoogle Scholar
  10. 10.
    Yazaki Y, Koga H, Ochi T et al (2016) Surgical management of recto-prostatic and recto-bulbar anorectal malformations. Pediatr Surg Int 32(10):939–944CrossRefPubMedGoogle Scholar
  11. 11.
    Alam S, Lawal TA, Pena A et al (2011) Acquired posterior urethral diverticulum following surgery for anorectal malformations. J Pediatr Surg 46(6):1231–1235CrossRefPubMedGoogle Scholar
  12. 12.
    Hong AR, Acuna MF, Pena A et al (2002) Urologic injuries associated with repair of anorectal malformations in male patients. J Pediatr Surg 37(3):339–344CrossRefPubMedGoogle Scholar
  13. 13.
    Srimurthy KR, Ramesh S, Shankar G et al (2008) Technical modifications of laparoscopically assisted anorectal pull-through for anorectal malformations. J Laparoendosc Adv Surg Tech A 18(2):340–343CrossRefPubMedGoogle Scholar
  14. 14.
    Koga H, Okawada M, Miyano G et al (2017) Is measuring the residual rectourethral fistula during laparoscopically assisted anorectal pull-through for male high/intermediate type imperforate anus beneficial? Mid-term follow-up. J Pediatr Surg 52(12):1994–1996CrossRefPubMedGoogle Scholar
  15. 15.
    Levitt M, Pena A (2006) Operative management of anomalies in males. In: Holschneider AM (ed) Anorectal malformations in children. Springer, Berlin, pp 296–302Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Hiroyuki Koga
    • 1
    Email author
  • Stephanie Y. Chen
    • 2
  • Hiroshi Murakami
    • 1
  • Go Miyano
    • 1
  • Takanori Ochi
    • 1
  • Geoffrey J. Lane
    • 1
  • Philip K. Frykman
    • 2
  • Atsuyuki Yamataka
    • 1
  1. 1.Department of Pediatric General and Urogenital SurgeryJuntendo University School of MedicineTokyoJapan
  2. 2.Division of Pediatric Surgery, Department of SurgeryCedars-Sinai Medical CenterLos AngelesUSA

Personalised recommendations