THE ANTERIOR SAGITTAL TRANSRECTAL APPROACH FOR TRAUMATIC URETHROVAGINAL FISTULA CLOSURE

The anterior sagittal transrectal approach (ASTRA) de- rived from the posterior sagittal anorectoplasty introduced by deVries and Pena in 1982 and was primarily developed for the treatment of anorectal malformations.1 We report the management of a recurrent traumatic urethrovaginal fistula using this technique. CASE REPORT A 10-year-old girl presented with a recurrent posttrau- matic fistula after a mine explosion in Afghanistan. Follow- ing the injury primary closure was performed twice, initially via a combined abdominovaginal procedure, and a secondary transvaginal closure was performed. Two years after the reconstructions the patient presented with recurrent urinary tract infections in combination with urge incontinence and additional permanent urinary drib- bling. Voiding cystourethrogram showed a recurrent fistula between the proximal urethra and the proximal third of the vagina (fig. 1, A). Additional urodynamic investigation re- vealed a bladder capacity of 110 ml, unstable detrusor activ- ity with intravesical pressure to 80 cm H2O and complete bladder emptying. An unimpaired upper urinary tract was confirmed by ultrasonography and excretory urography. Ure- throcystoscopy demonstrated an intact distal and mid ure- thra, while a wide proximal fistula to the vagina close to the bladder neck was detected. In this portion the vagina ap- peared uninjured and a normal cervix uteri was identified. However, on vaginoscopy no cervix could be found, indicating a separation of the vagina by the previous trauma (fig. 2, A). Based on these endoscopic findings, the ASTRA procedure was selected for fistula closure. Standard mechanical bowel preparation was performed for 2 days preoperatively with senna. With the patient in the prone position a midline incision was made from the anus to the vaginal introitus. The anterior rectal and posterior vag- inal walls were incised in the midline to the level of the peritoneal reflection. Following exposure of the dorsal vagi- nal wall a cicatricial obliteration of the mid vaginal portion with separation of the vagina in 2 parts was observed (fig. 2, B). The fistula was located at the proximal third of the vagina, and, therefore, could not be identified on vagino- scopy. Excision of the fistula and lateral mobilization of the surrounding tissue were performed, and the urethra was longitudinally sutured over a 10Fr catheter with interrupted sutures. A subcutaneous Martius flap was prepared out of the right labium and used as a secondary layer to cover the urethra. The vagina was repaired posterior to the Martius flap. Following the procedure a 10Fr suprapubic tube cystos- tomy was used for 4 weeks. Neither drains nor a protective colostomy was needed. Perioperative antibiotic treatment in- cluded metronidazole and cefuroxime, and was continued for 9 days after surgery. After urinary drainage for 4 weeks voiding cystourethro- gram confirmed complete fistula closure (fig. 1, B). At 3-month followup the girl was continent and voided without residual urine. Persistent urgency is treated with anticholin- ergics. DISCUSSION Urethrovaginal fistula in childhood is a rare condition, and, therefore, an evolving field. Following trauma the fis- tula in girls mainly occurs in the proximal part of the urethra