Trans-Fistula Anorectoplasty (TFARP): Our Experience in the Management of Anorectovestibular Fistula in Neonates

AIM The purpose of the study was to observe the outcome of trans-fistula anorectoplasty (TFARP) in treating female neonates with anorectovestibular fistula (ARVF). METHODS A prospective study was carried out on female neonates with vestibular fistula, admitted into the surgical department of a tertiary level children hospital during the period from January 2009 to June 2011. TFARP without a covering colostomy was performed for definitive correction in the neonatal period in all. Data regarding demographics, clinical presentation, associated anomalies, preoperative findings, preoperative preparations, operative technique, difficulties faced during surgery, duration of surgery, postoperative course including complications, hospital stay, bowel habits and continence was prospectively compiled and analyzed. Anorectal function was measured by the modified Wingspread scoring as, "excellent", "good", "fair" and "poor". RESULTS Thirty-nine neonates with vestibular fistula underwent single stage TFARP. Mean operation time was 81 minutes and mean hospital stay was 6 days. Three (7.7%) patients suffered vaginal tear during separation from the rectal wall. Two patients (5.1%) developed wound infection at neoanal site that resulted in anal stenosis. Eight (20.51%) children in the series are more than 3 years of age and are continent; all have attained "excellent" fecal continence score. None had constipation or soiling. Other 31 (79.5%) children less than 3 years of age have satisfactory anocutaneous reflex and anal grip on per rectal digital examination, though occasional soiling was observed in 4 patients. CONCLUSION Primary repair of ARVF in female neonates by TFARP without dividing the perineum is a feasible procedure with good cosmetic appearance and good anal continence. Separation of the rectum from the posterior wall of vagina is the most delicate step of the operation, takes place under direct vision. It is very important to keep the perineal body intact. With meticulous preoperative bowel preparation and post operative wound care and bowel management, single stage reconstruction is possible in neonates with satisfactory results.