ruation. Predictions of future problems such as amenorrhea in cases of atretic uteri, or hydrometrocolpos and retrograde menses can be made in the newborn period. Presentations of pelvic pain or amenorrhea as teenagers should prompt the assumption of anomalous gynecologic structures.
• Laparoscopically assisted anorectal approach
The laparoscopically-assisted anorectal approach consists in mobilizing and bringing the rectum through the pelvic floor sphincter muscles through a minimal posterior incision. Perianal dissection towards the laparoscopic light source favours accurate placement of a trocar to pull the rectum through the external sphincter muscle complex. Laparoscopically-assisted anorectal repair can either be performed in the newborn period without a colostomy or in a stage-approach. This new technique, described by KE Georgeson et al. needs further long-term evaluation in terms of fecal continence [24, 25].
• Anterior sagittal approach
Anterior sagittal approach, involving anterior perineal dissection (from the base of the scrotum to the posterior part of the anoderm), is used by some surgeons, with the aim of preserving the internal anal sphincter . But it should be noticed that this approach might damage the vesical nerve plexus when the rectourethralfistula is dissected up to its junction with the urethra. Furthermore, an internal sphincter saving technique has been devised when performing the posterior sagittal approach.
The posterior sagittal incision is relatively painless. In patients with a rectourethral fistula, the foley catheter stays in place for about 5–7 days, and occasionally longer. At two weeks postoperatively, anal calibration is performed, followed by a program of anal dilitations. The anus must be dilated twice daily and every week the size of the dilator is increased. The final size to be reached depends on the age of the patient. Once the desired size is reached, the colostomy can be closed. Dilatations are a vital part of the postoperative management to avoid a stricture at the anoplasty. After colostomy closure, severe diaper rash is common because the perineal skin has never before been exposed to stool.
• Functional Disorders
It is also the most important problem to avoid after definitive repair for female patients with rectovestibular or rectoperineal fistula and for male patients with rectobulbarurethral fistula, imperforate anus without fistula, and rectoperineal fistula. Failure to avoid constipation can result in megarectum and megasigmoid, and can lead to fecal impaction and overflow incontinence. The origin of the problem of constipation is unknown. It was originally thought that the perirectal dissection caused a degree of denervation that resulted in constipation. However, on careful review of the largest series of these patients, it became clear that those with the most benign defects and thus the least amount of perirectal dissection had the worst constipation.
The presence of a megarectum prior to the pull-through does correlate with postoperative constipation. Megarectum is more common in patients for whom a transverse or loop colostomy was performed in the newborn period. Constipation appears to be a hypomotility disorder secondary to chronic bowel dilatation. Or, perhaps it is the hypomotility that causes dilatation, which in turn results in constipation, creating a vicious cycle.
When a patient with a megasigmoid has been shown to be fecally continent, resection of the sigmoid has been found to dramatically reduce the patient's laxative requirements. The descending colon with normal caliber and normal motility is anastomosed to the rectum at the peritoneal reflection. This applies for a select group of patients with enormous daily laxative requirements to keep their colons clean. Performance of a new pull-through operation should be avoided so that the patient's rectal reservoir is preserved. Loss of the rectal reservoir could lead to a worse problem of incontinence with a patient who now has diarrhea.
The key in these patients is to manage constipation proactively and