V07-02: Anastomotic Posterior Urethroplasty in first year of life
There are no published cases of anastomotic urethroplasty in children less than one-year of age. Boys with a high imperforate anus have a recto urethral fistula.They are initially managed by Colostomy .The fistula usually occurs at the prostatomembranous junction. The trend is to perform a single stage posterior sagittal posterior anorectopexy (PSARP) with pull through and closure of fistula after the child is fit for surgery. Inadvertent injury to urethra during fistula repair may result in traumatic obliteration of the posterior urethra. The aim was to evaluate our outcomes of posterior urethroplasty in these cases.
A prospective database was maintained of infants with urethral injury. Amongst 1307 cases of PFUDD ,we managed 5 boys with posterior urethral injury after PSARP from 2012 to 2018. Follow up ranged from 6 months to 3 years. One of them was operated in a Live workshop, which video we wish to present. Iatrogenic injury was noticed after PSARP by the primary surgeon. Suprapubic catheter was inserted for retention of urine. Surgery was planned once the boy was 10Kg in weight. Evaluation was done using retrograde urethrogram (RGU) and voiding cystourethrogram (VCUG) along with endoscopy from above and below. Urethroplasty was performed early to avoid complications from long-term suprapubic drainage and promotion of physiological voiding.
5 boys aged less than one year had iatrogenic posterior urethral injuries. All of them were born with a high imperforate anus and recto urethral fistula. PSARP was complicated by posterior urethral transection resulting in an obliterated urethra. This was initially managed with a supra-pubic catheter followed by anastomotic urethroplasty. 4 boys required crural separation and inferior pubectomy. All 5 boys had an uneventful recovery with only one requiring a laser direct vision internal urethrotomy of an annular stricture. One boy has some incontinence which is related to the poor bladder neck function.
Iatrogenic urethral injuries are rare in infants but can occur in PSARP. It is challenging to perform Crural separation, inferior pubectomy in a infant. Expert management can offer early physiologic voiding in such subgroup of patients.