Recto-urinary Fistula Following a Transanal Proximal Rectosigmoidectomy

• 11-yr-old developmentally delayed male with a history of chronic constipation presents with painful defecation and frequent soiling.
• He would often have 10-15 d between bowel movements and often had abdominal pain and distention.
• On physical examination, he had multiple palpable fecalomas, a normal anus and normal spine.
• He underwent anorectal manometry, which was normal.
• He was referred with barium enema. The barium enema showed fecal impaction, largely dilated colon and a megarectum.
• Constipation diet, laxatives and frequent enemas were initiated.
• He never had a spontaneous stool after taking oral laxatives.
• Second barium enema showed persistent megarectum and sigmoid.
• Transanal proximal rectosigmoidectomy was performed without any interoperative complications.
• Hematuria was noted at the end of the case.
• Foley was left in place for 48 h, then removed.
• Patient was discharged on postoperative day 8 after spontaneously voiding and stooling.
• On postoperative day 25, patient was noted to have dysuria and had urine passing through the anus.
• VCUG was performed, which confirmed recto-urinary fistula.
• Patient underwent diverting colostomy, but continues to pass urine through the anus.

Takeaways

• When all the medical resources have been exhausted after proper bowel management, then the surgeon needs to consider surgical treatment.
• Every surgeon needs to decide what operation will be performed based on his/her skills, knowledge, experience and own circumstances.
• This operation requires an experienced and knowledgeable surgeon with additional training in colorectal surgery to successfully perform this technique.
• Patients with mega-rectosigmoid do not require biopsy.
• Options for management of patients with mega-rectosigmoid include bowel management.
  • Surgical options include: sigmoidectomy, sigmoidectomy with appendicostomy, complete transanal rectosigmoidectomy leaving 5 cm of rectum to function as a reservoir to prevent fecal incontinence.
• When performing dissection of the anterior rectal wall, the surgeon must be cautious of damaging the urethra.
• When performing a surgery for fistula, there should always be normal rectal wall in front of the urethral sutures. If sutures of the urethra are adjacent with the sutures of the rectal wall, the patient is at increased likelihood for recurrence of fistula.