Management of imperforate anus with recto-urethral fistula.

This paper is concerned with cases of imperforate anus with recto-urethral fistula in males and some cases with high recto-vaginal fistula in females, all being cases of the type III described by Ladd and Gross (1934) or the high level imperforate anus described by Denis Browne. These cases still present difficult problems (Browne, 1955; Forshall, 1957; Brayton and Norris, 1958; Gross, 1959). Decisive advances in the management of this anomaly started with the one-stage abdominoperineal pull-through procedure, first suggested by Macleod (1880), first published in 1948 by Rhoads, Pipes and Randall and independently carried out by Norris, Brophy and Brayton (1949) since 1943. Although this method enables the surgeon to free the blind-ending rectum very close to the rectal wall, this procedure may lead to injury of the delicate nerve junctions in the true pelvis and endanger the blood supply of the neighbouring organs, especially, if as in most cases, the lowest part of the rectal pouch descends distal to the fistula (Brayton and Norris, 1958; Rehbein, 1959), is distended as in newborns, is filled by meconium and has a thin wall (Potts, Riker and DeBoer, 1954; Browne, 1955). From the recent studies of Scott and Swenson (1959) we know that in ano-rectal malformations the nerve fibres in the true pelvis are present, but take a slightly different course. Their preservation may improve post-operative rectal control; damage to them may destroy all hope of continence, which can usually follow if the pubo-rectalis sling is anatomically well sited and functions well (Snyder, 1961). From experience gained in rectal surgery in adults it is probable that damage to the nerve supply in the true pelvis may lead to disorders of bladder function and sexual potency (Bacon and Ross, 1954; Bruch, 1955; Stelzner, 1957), and Brayton and Norris (1958) state that the widespread use of the abdomino-perineal operation for imper-