López Pedro José, Guelfand Miguel, Angel Lorena, Paulos Angélica, Cadena Yair, Escala José M, Letelier Nelly, Zubieta Ricardo
Department of Urology and Pediatric Surgery, Children's Hospital Dr, Exequiel Gonzalez Cortes, Santiago, Chile.
Arch Esp Urol. 2010 May;63(4):297-301.
With the increased use of minimally invasive surgery, the urethral diverticulum after anorectal surgery has become an issue. The few cases reported have been managed by surgical excision. We hereby report a case of urethral diverticulum after a laparoscopically-assisted anorectal pull-through (LAARP)procedure with a successful outcome after a period of active surveillance.
A full-term boy who displayed a high anorectal malformation (ARM) and a rectoprostatic fistula underwent colostomy on the first day. He also showed associated malformations: bilateral low-grade reflux, horseshoe kidney and thoracic hemivertebrae; however, there were no signs of spinal cord tethering. Antimicrobial prophylaxis was started.
At the age of 3 months, he underwent a LAARP with a 3 abdominal-port approach. After complete dissection of the distal bowel, the recto-prostatic fistula was identified and tied with metallic clips. A 10 mm trocar was inserted through the centre of the sphincteric complex, which had been previously identified under laparoscopic view during perineal electrical stimulation. The anorectal pull-through was accomplished without tension. The bladder remained stented for 14 days. On the 18th postoperative day, a voiding cystourethrogram (VCUG) showed a 15 X 5 mm image of the diverticulum at the level of the membranous urethra. After 6 months, a new VCUG showed a normal urethra with neither signs of the diverticulum nor strictures; persistence of grade 2 reflux on the right side and resolution of the reflux on the left. When the boy was one year old his colostomy was closed uneventfully. Six months later he had not come into the emergency since the operation and voided with a normal flow.
This report suggests that LAARP is a feasible approach for ARM, although urethral diverticulum is a major concern. It may evolve without complications, and eventually resolve spontaneously. Active surveillance might be an option in selected asymptomatic patients; however a longer follow-up is advised to constitute better evidence supporting that policy.
随着微创手术使用的增加，肛肠手术后的尿道憩室已成为一个问题。已报道的少数病例通过手术切除进行处理。我们在此报告一例腹腔镜辅助下肛肠拖出术（LAARP）后出现尿道憩室的病例，经一段时间的积极监测后取得了成功的结果。
一名足月男婴，患有高位肛肠畸形（ARM）和直肠前列腺瘘，于出生第一天接受了结肠造口术。他还伴有其他畸形：双侧低度反流、马蹄肾和胸半椎体；然而，没有脊髓拴系的迹象。开始进行抗菌预防。
3个月大时，他采用三孔腹腔镜入路接受了LAARP。在完全游离远端肠管后，发现直肠前列腺瘘并用金属夹结扎。通过先前在会阴电刺激时腹腔镜观察确定的括约肌复合体中心插入一个10毫米套管针。肛肠拖出术顺利完成，无张力。膀胱留置支架14天。术后第18天，排尿性膀胱尿道造影（VCUG）显示在膜部尿道水平有一个15×5毫米的憩室影像。6个月后，新的VCUG显示尿道正常，既无憩室迹象也无狭窄；右侧仍存在2级反流，左侧反流消失。患儿1岁时，结肠造口术顺利关闭。6个月后，自手术以来他未出现急诊情况，排尿正常。
本报告表明，LAARP是治疗ARM的一种可行方法，尽管尿道憩室是一个主要问题。它可能无并发症地发展，并最终自发消退。对于部分无症状患者，积极监测可能是一种选择；然而，建议进行更长时间的随访以提供更好的证据支持该策略。
