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Bladder Dynamics in Patients with Anorectal Malformations undergoing Reoperative Posterior Sagittal Anorectoplasty
Uchenna Kennedy, MD, Michael Daugherty, MD, Jason Frischer, MD, Curtis Sheldon, MD, Pramod Reddy, MD, Eugene Minevich, MD, Andrew Strine, MD, William DeFoor, MD, Paul Noh, MD, Brian Vanderbrink, MD.
Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.

Background
Anorectal malformations (ARM) are associated with genitourinary anomalies and bladder dysfunction. The traditional approach for surgical repair is a posterior sagittal anorectoplasty (PSARP). Historically, a primary PSARP has been found to have a negligible effect on bladder dynamics. However, little is known about the effects of reoperative PSARP (rPSARP) on bladder function.
We evaluated patients undergoing rPSARP and assessed changes in bladder dynamics. We hypothesized that a high rate of bladder dysfunction existed in the cohort.
Methods
We performed a retrospective chart review of all patients with ARM undergoing rPSARP at a single institution from 2008 2015. Only patients with Urology follow-up were included in our analysis. Data was collected regarding location of the original level of ARM, coexisting spinal anomalies and indications for reoperation. We assessed urodynamic variables and bladder management (defined as either voiding, catheterizing [CIC] or diverted) before and after rPSARP. Negative bladder management changes were defined as change from voiding to CIC or CIC to urinary diversion.
Results
A total of 172 patients were identified, of which 109 patients met inclusion criteria with a median follow-up of 23.9 months (range, 0 - 101). 61 (55.9%) were males and spinal cord anomalies existed in 46 (42.2%) patients. Indications for rPSARP included mislocation of anus within sphincter complex (n=50), posterior urethral diverticulum (PUD; n=21), rectal prolapse (n=10) and stricture (n=24).
Within 1 year following rPSARP, 11 patients (12.5 %) had a negative change in bladder management. At last follow-up, this increased to 16 patients (18%). Of these 16 patients, 9 (56.3%) had a spinal anomaly and the most common original ARM levels in females were rectovestibular (5) and in males rectoprostatic fistulas (6). Postoperative bladder management changed in patients with mislocation (p <0.0001), PUD (p 0.038) and stricture (p 0.005) as indication for rPSARP but not for rectal prolapse (p 0.143).
Twenty-one patients had pre-rPSARP- and postoperative urodynamics for comparative analysis. Detrusor overactivity decreased postoperatively (preoperative 100% vs 42.8% at last follow-up; p 0.0005); there was simultaneous increase of anticholinergic use. There was no change in median %age expected bladder capacity (preoperative 114% vs 123% at last follow-up; p 0.543).
Conclusions
There is a known risk of pre-existing bladder dysfunction in the ARM population and those patients who undergo rPSARP warrant close attention for this clinical entity. A negative postoperative change in bladder management was found in 18% of our cohort, however this is most likely multifactorial in etiology. Our study highlights the importance of long-term urological follow-up in this patient group.
Indication for Redo Bladder Management P-Value
PreoperativePostoperative 1 yearMost recent
Mislocation424242< 0.0001
Voiding30 (71.4%)26 (61.9%)23 (54.7%)
CIC9 (21.4%)13 (30.9%)17 (40.4%)
Diversion3 (7.2%)3 (7.2%)2 (4.8%)
PUD/Fistula1616160.038
Voiding14 (87.5%)11 (68.8%)10 (62.5%)
CIC1 (6.2%)3 (18.8%)4 (25.0%)
Diversion1 (6.2%)2 (12.5%)2 (12.5%)
Stricture1919190.005
Voiding14 (73.6%)11 (57.9%)11 (57.9%)
CIC2 (10.5%)6 (31.6%)7 (36.8%)
Diversion3 (15.8%)2 (10.5%)1 (5.2%)
Prolapse8880.143
Voiding5 (62.5%)4 (50.0%)4 (50.0%)
CIC2 (25.0%)2 (25.0%)4 (50.0%)
Diversion1 (12.5%)2 (25.0%)0 (0.0%)
PUD = posterior urethral diverticulum


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