Taking “Trans-ano-rectal” out of ASTRA: an anterior sagittal approach without splitting the rectum
Kathy H. Huen, MD, Sarah A. Holzman, MD, Carol A. Davis-Dao, PhD, Elias J. Wehbi, MS, MS, Antoine E. Khoury, MD.
Children's Hospital of Orange County/ UC Irvine, Orange, CA, USA.
BACKGROUND: The anterior sagittal trans-ano-rectal approach (ASTRA) provides excellent exposure to the urethra and vagina for partial or total urogenital sinus mobilization and subsequent reconstruction for patients with urogenital sinus anomalies. However, the division of the anterior anal external sphincter and the rectal wall in ASTRA incurs morbidity, which include fecal incontinence if one veers from the midline, and increased risk of wound infection due to fecal soilage.
METHODS: We demonstrate a modified technique to the ASTRA without splitting the anterior rectal wall in a 4.5 year-old girl with a persistent urogenital sinus in the setting of simple virilizing 21-hydroxylase deficiency congenital adrenal hyperplasia.
RESULTS: The anterior sagittal approach without rectal wall splitting achieves comparable exposure for urogenital sinus mobilization and subsequent reconstruction. In this case, we achieved excellent vaginal length and mobilization, with the posterior vaginal wall anastomosed directly to the perineum, avoiding the use of perineal skin flaps. The patient experienced no postoperative complications within the 3 month follow up period.
CONCLUSIONS: The anterior sagittal approach without splitting the rectum minimizes risk of fecal incontinence and wound dehiscence, while achieving good exposure for urogenital sinus mobilization and reconstruction. Although follow up is short, we believe this technique can be safely considered as the initial approach for these complex reconstructive procedures.
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