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Subject: SV: SV: anorectal malformations
Date: Mon, 22 Aug 2016 09:24:40 +0200

Your paper is of interest.

I just wonder how you solve the problem with fistula to the urinary tract or the vulvae.


                      Dear Dr. Arnbjornsson, thanks for asking.

  1. In order to understand each other, we must use the terms adopted in the anatomy. The distal intestine, located caudal puboсoссygial  line (P-C line) is called the anal canal. Its length in term newborns is 1.7 cm. The rectum is located proximal to Р-С line.  We need to divide concepts such as the fistulous course (tract) and fistula orifice (hole).  The fistulous tract has a length. The fistula hole is a connection (ring) between two cavities or the place outlet of a cavity to the outside.  

  2. Analysis of the article reveals the contradiction between the text and some objective indices.  If we know that the normal anal canal length is 1.7 cm, the distance between the ectopic anal canal and anal dimple is 02- 0.3 cm, but not 1 cm, as it is written in the article (figure 1).  On the third day during fistulography the contrast medium has got into the anal canal, filled with meconium (figure 1, A).

Day 3
Day 3
Day 3
Day 4

Figure 1.


The contrast agent has not penetrated into the anal canal during urethrography on 4 day because he could not get there without going through a cyst.

Thus, a contrast agent that is in the opened anal canal got there the day before during fistulography.There is no connection between the anal canal and the urethra. Long fistulae in the subcutaneous tissue is very thin and typically not functioning. If the procedure of the perineum perforation would be made, the fistulous opening would be located outside the anal canal.The anal canal is constantly open, because the X-Ray study was carried out on 4-th day after birth.The rectum has accumulated a large amount of meconium and gas. However, newborns with ARM often come in the first day after birth, when the meconium and gas in the rectum are few volume and they do not create threshold pressure for the disclosure of the anal canal. In these cases, the anal canal, as in all humans is in the closed condition and gas with meconium are located in the rectum, i.e. 1.7 cm from the anal fossa. Unfortunately, most pediatric surgeons these cases rank as the intermediate or high types ARM. They remove the anal canal calling it a fistula or rectal pouch, move in its place the extended rectum, separated the anal canal from the levator ani muscle with damage puborectalis muscle.


Figure 2.  Colostography.

The introduction of contrast medium under high pressure has led to the disclosure of the anal canal. An asterisk indicates the fistula hole. There is no fistula channel (tract). The figure 2,"B" shows a state of anorectum after the perineum perforation procedure (theoretically).


3. I performed the perineum perforation procedure in 4 patients without visible fistula. One of them died from complications of esophageal atresia. The remaining three patients after 1.5-2 years had the normal function of fecal retention and defecation.  At the Belarusian center of pediatric surgery (Minsk) more than 100 patients with vestibular and perineal  fistulas were operated.  The anus in the ring of the external anal sphincter under the protection of colostomy was created.  After that, the ectopic anus was sutured.   Sometimes fistulas were opened again and sometimes it was repeatedly but it had no effect on the anorectal function. I offer a tool for the creation of the anus in a normal place. I think that this will improve the results of treatment. In order to prevent the recurrence of a fistula should be during its suturing to destroy the mucosa (chemicals or cold) in the surgical wound.

On the basis of histological studies it is known that most of the urethral fistulas or fully closed, or so narrow that they do not function. At low type as shown in Figure 2, If it is needed, the hole fistula can sew up from thedisclosed anus.

In many cases, during the excision of the anal canal from urethra (PSARP), the hole in the urethra is formed. But this hole is iatrogenic origin.


4. Nature has created a convincing proof, that the intestine, located caudal P-C line in patients with ARM is the functioning anal canal. This applies to the rare cases where ectopic anus wide enough to ensure the normal evacuation of feces.


(Mehboob M,at al.A functional ectopic vaginal anus: a rare clinical entity. J Coll Physicians Surg Pak. 2012 Oct;22(10):661-2).

"A case of functional ectopic vaginal anus is presented in a 20 years old girl. Patient complained of passage of stool through her vagina. She was continent and had no complaint of constipation".


With respect

    Michael Levin


P.S.   You can follow the discussion on website ( or participate in discussions through my mail ( 

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