title: Surgical treatment of high urogenital sinuses using the anterior sagittal transrectal approach: a useful strategy to optimize exposure and outcomes.
abstract: OBJECTIVE
  Surgical management of the high urogenital sinus remains challenging. The anterior sagittal transrectal approach provides optimal exposure, facilitates vaginal dissection and separation from the urethra, and allows reconstruction of the bladder neck musculature. In this study we report our initial experience with this technique.
  
  
  METHODS
  We performed a retrospective review of a 6-year multi-institutional experience treating patients with a urogenital sinus anomaly using the anterior sagittal transrectal approach without preoperative colostomy or prolonged postoperative fasting. Variables analyzed included patient age, associated malformations, the need for additional procedures and surgical outcomes.
  
  
  RESULTS
  A total of 23 children with a mean age of 2.3 years (range 3 months to 17 years) who underwent surgery between 2003 and 2010 were included in the study. Mean followup was 3.4 years (range 14 months to 7 years). All children had a high urogenital sinus with (16) or without (7) congenital adrenal hyperplasia. There were 3 isolated cases treated with additional procedures. Only 1 anterior sagittal transrectal approach related complication was encountered when a perineal infection developed in a child and required temporary diverting colostomy without compromising the repair. There were no postoperative urethrovaginal fistulas. All toilet trained patients were continent for feces and most were voiding normally per urethra (21), except for 2 with associated urological malformations. There were 15 patients who underwent followup examination under anesthesia, and demonstrated separate urethral and vaginal openings.
  
  
  CONCLUSIONS
  The anterior sagittal transrectal approach provides excellent exposure for the management of a high urogenital sinus, facilitating the separation of urogenital structures. Good outcomes in terms of urinary/fecal continence as well as the absence of urethrovaginal fistulas were achieved in the majority of cases, supporting its consideration for the surgical management of this congenital abnormality.
authors.affiliation: Division of Urology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada. pippi.salle@sickkids.ca
authors.forename: João L Pippi
authors.initials: JL
authors.lastname: Salle
authors.forename: Armando J
authors.initials: AJ
authors.lastname: Lorenzo
authors.forename: Lisieux E
authors.initials: LE
authors.lastname: Jesus
authors.forename: Bruno
authors.initials: B
authors.lastname: Leslie
authors.forename: Abdulnasser
authors.initials: A
authors.lastname: AlSaid
authors.forename: Francisco Nicanor
authors.initials: FN
authors.lastname: Macedo
authors.forename: Venkata R
authors.initials: VR
authors.lastname: Jayanthi
authors.forename: Roberto
authors.initials: R
authors.lastname: de Castro
mesh_terms: D000293:Adolescent; D000312:Adrenal Hyperplasia, Congenital / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D012734:Disorders of Sex Development / Q000601:surgery*; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D019651:Plastic Surgery Procedures / Q000379:methods*; D012007:Rectum; D012189:Retrospective Studies; D016896:Treatment Outcome; D013520:Urologic Surgical Procedures / Q000379:methods*