title: Rotation of the amputated fistula tract for the management of congenital urethral-enteric fistula with severe urethral stenosis: a novel technique with long-term outcomes.
abstract: OBJECTIVE
  Urethral-enteric fistulae with hypoplastic/atretic distal urethra in boys with anorectal malformations are amenable to management via sequential dilation of the distal urethra (P.A.D.U.A.) and subsequent repair of the fistula, but failure of this technique occasionally requires complex reconstruction. We present a novel surgical approach, along with long-term results, that incorporates rotation of the amputated fistula tract (RAFT) in boys with H-type urethral-enteric fistulae.
  
  
  METHODS
  The charts of four patients undergoing the RAFT procedure were reviewed. All had previously failed P.A.D.U.A. Surgical principles were similar in all cases: the fistula tract was amputated as close to the bowel as possible. A tubularized or on-layed urethra was then fashioned from preputial skin and anastomosed to the distal end of the urethral fistula. The distal end of the neourethra was then brought to the tip of the penis, or anastomosed to the proximal end of the patent distal urethra.
  
  
  RESULTS
  Mean age was 12.3 months, and there was a mean follow up of 10.2 years. All four patients had a rectourethral fistula as a component of VACTERL, with a urethral deficit of 7-11 cm. All had a functionally intact urethra on reconstruction, with normal continence and bladder neck closure. Two patients needed further bladder augmentation with a Mitrofanoff channel for poor bladder compliance. Both boys who were post-pubertal in this series report normal sexual function with antegrade ejaculation.
  
  
  CONCLUSIONS
  The RAFT technique represents a viable reconstructive option for congenital H-fistulae with distal urethral stenosis, with excellent long-term results. It provides boys with normal urethral function, along with intact urinary continence and antegrade ejaculation. This technique may be of particular utility in patients after failed P.A.D.U.A., or in whom a staged buccal onlay graft is not feasible.
authors.affiliation: Department of Pediatric Urology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Kaye
authors.forename: Arun K
authors.initials: AK
authors.lastname: Srinivasan
authors.forename: Martin A
authors.initials: MA
authors.lastname: Koyle
authors.forename: Edwin A
authors.initials: EA
authors.lastname: Smith
authors.forename: Kate H
authors.initials: KH
authors.lastname: Kraft
authors.forename: Moneer K
authors.initials: MK
authors.lastname: Hanna
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Kirsch
mesh_terms: D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D008297:Male; D019651:Plastic Surgery Procedures / Q000379:methods*; D012003:Rectal Fistula / Q000150:complications / Q000151:congenital / Q000601:surgery*; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014521:Urethra; D014525:Urethral Stricture / Q000209:etiology / Q000601:surgery*; D014548:Urinary Fistula / Q000150:complications / Q000151:congenital / Q000601:surgery*; D013521:Urologic Surgical Procedures, Male / Q000379:methods*