Posterior sagittal anorectoplasty is superior to sacroperineal-sacroabdominoperineal pull-through: a long-term follow-up study in boys with high anorectal anomalies.

BACKGROUND/
PURPOSE: It is unclear which surgical method offers best long-term functional results in patients with high anorectal anomalies. The purpose of this study was to compare the long-term outcome of sacroperineal-sacroabdominoperineal pull-through (SP-SAP) to that of posterior sagittal anorectoplasty (PSARP).
METHODS: Only boys with high anorectal anomalies (rectourethral fistula) were included in the study to get fully comparable patient groups. From 1975 to 1987, 36 consecutive patients underwent anorectal reconstruction: 19 had SP-SAP (1975 to 1983) and 17 PSARP (12 with internal sphincter-sparing technique, 1983 to 1987). The late bowel function (age at follow up, SP-SAP, 19 years; range, 15 to 22; PSARP, 13 years; range, 10 to 19) was evaluated by clinical interview and examination, and anorectal manometry.
RESULTS: Six (35%) of the PSARP patients and one (5%) of the SP-SAP patients (P < .04) were always clean without any adjunctive measures. Three PSARP patients and two SP-SAP patients stayed clean with daily enemas. In the PSARP patients with soiling, the median frequency of soiling episodes in a month was four (range, 1 to 16), in the SP-SAP patients, 20 (range, 2 to 28, P < .001). None of the SP-SAP patients but 8 of 17 of the PSARP patients had constipation requiring diet or oral medication. Two PSARP patients and four SP-SAP patients had occasional faecal accidents. The median daily bowel movements in the PSARP group was one (range, one to four) and in the SP-SAP group, three (range, one to five, P < .001). The PSARP patients had significantly higher anorectal resting and squeeze pressures and voluntary sphincter force (cm/H2O, PSARP: mean resting, 47+/-9; mean squeeze, 106+/-29; mean voluntary sphincter force, 60+/-22; SP/SAP: mean resting, 27+/-10; mean squeeze, 68+/-22; mean voluntary sphincter force, 41+/-17; P < .01). Thirteen (76%) of the 17 PSARP patients and none of SP-SAP patients had positive rectoanal reflex indicating functional internal sphincter.
CONCLUSIONS: In boys with high anorectal anomalies, PSARP clearly is superior to sacroperineal and sacroabdominoperineal pull-through in terms of long-term bowel function and faecal continence.