Simultaneous diagnosis of vesico ureteral reflux and recto-urinary tract fistula in boys with anorectal malformation: Methodology and outcome

Introduction: Most centers treating patients with anorectal malformation (ARM) will screen for anomalies of the kidneys and urinary tract by using ultrasonography. There is no consensus on whether screening for vesico-ureteral reflux (VUR) should occur. To meet the diagnostic needs of ARM patients a method was developed to include a simultaneous VUR diagnosis and pre-reconstructive fistula work-up in a combined voiding urethral cystogram (VCUG), colostogram, and retrograde urethrogram (RUG) examination. Material and methods: The study was undertaken for male ARM patients diagnosed and operated on between 1st of January 2013 to 31st of December 2023 at a national specialized medical center for ARM covering 4.5 million residents. Since 2013, all patients with ARM have been prospectively registered in a local ARM-register. Inclusion criteria were male ARM-patients without perineal fistula, who had pre-reconstruction work up and reconstructive surgery for ARM performed at the center. For VUR and recto-urethral fistula diagnosis, the imaging procedure consisted of three consecutive parts: VCUG, high pressure colostogram and, if needed for correct fistula imaging a RUG. Results: During the period, 37 male patients with ARM and recto-urethral- or no fistula were treated at the center. Eleven patients were excluded leaving 26 patients eligible for inclusion. 18 patients (69 %) had no VUR, 4 (15 %) had VUR grade 3–5. Eleven of 26 patients, (42 %), presented clinical signs of a having an open recto-ur fistula. For visualization of fistula presence and level, 3 patients (12 %) had a VCUG only, 13 (50 %) VCUG and colostogram, and in 10 patients (38 %) a retrograde urethrogram was added. During reconstruction, no fistula was identified in four patients (15 %) while three (12 %) had recto-bulbar fistula, 14 (54 %) recto-prostatic fistula and five (19 %) recto-bladder neck fistula. Discussion: We present a method for a simultaneous diagnosis of VUR and ARM-subtype during pre-reconstructive work-up in patients with complex ARM. The incidence of VUR grade 3 or higher was 15 %, with poor correlation between high grade VUR and dilatation of the upper urinary tract identified on ultrasound. The accuracy of open fistula presence was 25/26 (96 %) while the accuracy for the anatomic display of fistula level varied from 80 % in recto-bladder neck fistula, to 93 % in recto-prostatic-, and 100 % in recto-bulbar fistula. Conclusion: We found the method of a simultaneous diagnosis of VUR and recto-urinary tract fistula was a good option with low risks for preoperative evaluation in male patients with complex ARM.