Separating Rectum from Urethra During Posterior Sagittal Anoplasty / PSARP
Colorectal Center surgeons at Cincinnati Children's Hospital Medical Center provides information about separating the rectum from the urethra in Posterior Sagittal Anoplasty / PSARP.
The mucosal stitches in place and the beginning of the submucosal dissection. | 
The dissection between rectum and urinary tract. The submucosal dissection has been concluded and now we have found a nice plane of separation between the rectum and urinary tract. | 
The rectum completely separated. |
A series of 6-0 silk stitches are placed, taking the rectal mucosa immediately above the fistula and immediately below the pectinate line. Those stitches will serve to exert uniform traction without injuring the tissue itself.
Bear in mind that the anterior rectal wall immediately above the fistula is completely fused to the posterior urethral wall forming a common wall.
In order to protect the urinary tract and the important structures located there (vas deferens, seminal vesicles and prostate), a submucosal dissection must be carried out beginning at the upper border of the fistula for about one cm above it, then the dissection between the urinary tract and rectum must be continued taking full thickness of the rectum.
Before the dissection is started in those cases where the catheter was passed into the rectal lumen, it is necessary to relocate the catheter into the urinary tract.
For this, we ask an assistant to get below the sterile field and pull the catheter out slowly while we redirect the tip of it into the urethra, then to push the catheter back in and fix it with tape to the penis.
While pulling the rectum upwards, the anterior rectal wall can be seen which has a full-thickness normal appearance in the upper part, and then a denuded distal portion that has only mucosa from the previous submucosal dissection.
The urethral fistula is sutured with interrupted 5-0 long-term absorbable sutures.
For more information or to request an appointment, please contact the Colorectal Center at Cincinnati Children's.
