function. Sometimes all three goals are achieved, sometimes only two, often only one, and occasionally none .
Prognostic factors include the quality of the sacrum, the quality of the muscles, and the length of the common channel. We have arbitrarily defined two groups of patients. The repair of patients with a common channel less than three cm is reproducible and is feasible for most pediatric surgeons. For patients with a common channel greater than three cm, the repair should be performed at a specialized center by a surgeon with experience managing the urologic anomalies and able to performing complex vaginal reconstructions. If the common channel is less than 3 cm, the posterior sagittal approach without an abdominal approach can be used to repair the defect.
For patients with a common channel greater than three cm, a laparotomy is usually required. Often the vagina and urinary tract must be separated trying to gain length, and the urethra must then be reconstructed. The surgeon must be prepared to open the bladder and to reimplant the ureters if necessary. Complex vaginal mobilizations are often required and frequenly a vaginal replacement with small intestine or colon is necessary. The pullthrough of the rectum is similar to other anorectal malformations. It is the repair of the vagina, the urethra, and the associated urologic defects that represents the main surgical challenge. A large vagina can be an advantage during the definitive repair because the surgeon can more easily mobilize it and has more alternatives for the vaginal repair. About 50% of patients have various degrees of vaginal or uterine septation. These can be totally or partially repaired during the main operation. The precise gynecologic anatomy must be ascertained either during the main repair or during colostomy closure (if a laparotomy was not required during the main repair). We have learned that approximately one third of our patients have obstructed Mullerian structures which can lead to severe problems resulting from retrograde menstruation. 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 a