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The “Goblet” incision, a new rectal-sparing anterior sagittal approach
Ricardo Zubieta, M.D., Pedro-Jose Lopez, M.D., Soledad Celis, M.D., Francisco J. Reed, M.D., Alejandra López, M.D., Danielle Reyes, M.D., Francisca Yankovic, M.D., Nelly Letelier, M.D..
Hospital Exequiel Gonzalez Cortes, Santiago, Chile.

Background
The Anterior Sagittal Trans-Rectal Approach (ASTRA) has been widely used among the paediatric urologists, becoming a highly recommended option for the surgical treatment of high urogenital sinus, vaginal malformations, complex urethral trauma and some genitourinary tumours. ASTRA´s anorectal wall incision involves bowel preparation, with a long post surgical recovery time and risk of local or extended infections. Our aim is to present a less invasive modification of ASTRA, with no need for rectal wall incision, using the same surgical field but with fewer post surgical complications.
Material and Methods
Prospective study over every patient with ASTRA surgery indication between January 2012 and May 2013 in which the "Goblet" incision was used. Without bowel preparation, with prophylactic antibiotics and in prone position, a vertical midline perineal incision (from the vulvar fork to the rectum in girls, and from scrotum base to rectum in boys) was made. Then, preserving completely the rectal wall, a “Goblet” shaped transverse concave incision, between the rectal mucosa and skin transition tissue, was performed. Technical aspect, complications and follow-up were analysed
Results
A total of 7 patients fulfilled inclusion criteria, 5 girls and 2 boys. The diagnoses were high urogenital sinus (>2 cm) in 3 patients, vaginal septum in 2, prostatic rhabdomyosarcoma and urethral duplication IIA 2 Y type (Effman) in 1 cases each. After surgery, all patients were fed few hours later. No protective colostomy was used. Patients were discharged with in the next 3 days with no complications. After an average 8 months follow up (r:4-13), all patients presents with good outcome from their surgery and faecal continence is normal in all on them.
Conclusion
"Goblet" incision approach has demonstrated to be feasible and to present the same comfort to perform the surgery with an excellent surgical field as the traditional ASTRA approach. As it involves less tissue “aggression” there might be less post operatory complication risks. It allows an earlier feeding, shorter hospitalization stay, less discomfort and avoids bowel preparation before surgery. This represents an initial report about a new surgical approach alternative for the vaginal, prostatic and urethral pathology, which can reduce the total anterior sagittal approach indication in some particular cases.


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