Urethral Diverticulum After Laparoscopic – Assisted Anorectal

Urethral Diverticulum After Laparoscopic – Assisted Anorectal Pullthrough (LAARP) for
Anorectal Malformation: Is It Always Necessary to Resect the Diverticulum?
López P.J., Guelfand M.*, Cadena Y., Tavares A., Escala J.M., Retamal M.G., Letelier N., Paulos A., Zubieta R.
Department of Urology and Pediatric Surgery*
Hospital de niños Dr. Exequiel González Cortés, Santiago, Chile
Introduction
With the increased use of minimally-invasive
surgery, the urethral diverticulum after anorectal
surgery have become an issue. The few cases
reported, have been managed by surgical excision.
We report a case of urethral diverticulum after a
(LAARP) with a successful outcome following a
period of active surveillance.
Case Report
A full-term boy who presented with a high anorectal
malformation (ARM) and a recto-prostatic fistula
underwent a colostomy at 1st day. Associated
malformations included bilateral low grade refllux, a
horseshoe kidney and a thoracic hemi-vertebrae;
no signs of spinal cord tethering. Antimicrobial
prophylaxis was started. At 3 month, he underwent
a LAARP with a 3 abdominal-port approach (Fig.1).
Fig.2
After 6 months, a new VC 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 (Fig.6).
A 10 mm trocar was inserted through the centre of
the sphincteric complex, which was previously
identified under laparoscopic view during perineal
electrical stimulation. (Fig.3).
Fig.6
Fig.3
Anorectal pullthrough was accomplished without
tension. (Fig.4)
At 1 y.o. the colostomy was closed uneventfully. Six
months later, he has remained UTI free and voiding
with a normal flow.
Conclusions
Fig.1
After complete dissection of the distal bowel, the
recto-prostatic fistula was identified and ligated with
metallic clips. (Fig.2)
Fig.4
Bladder remained stented for 14 days. On the 18th
postoperative day, a voiding cystometrogram (VC)
showed a 15 X 5 mm diverticular image at the
level of the membranous urethra (Fig.5).
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 resolves
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.