Multiple Choice Questions on High Anorectal Malformation with Recto-urethral Fistula
Question 1
A 2-day-old male neonate presents with imperforate anus. Contrast studies reveal a high anorectal malformation with recto-prostatic urethral fistula. What is the primary surgical approach recommended for this patient?
A) Immediate perineal anoplasty B) Posterior sagittal anorectoplasty (PSARP) without colostomy C) Diverting colostomy followed by definitive repair D) Immediate laparoscopic-assisted anorectoplasty (LAARP) E) Transanal endorectal pull-through
Answer: C) Diverting colostomy followed by definitive repair 1, 2
Question 2
During surgical planning for a 3-month-old with high ARM and recto-prostatic urethral fistula, which imaging study is most valuable for determining the precise anatomy of the fistula?
A) Plain abdominal radiograph B) Abdominal ultrasound C) Distal colostography D) MRI pelvis without contrast E) Retrograde urethrogram
Answer: C) Distal colostography 3
Question 3
A 4-month-old boy with high ARM and recto-urethral fistula is scheduled for definitive repair. Which of the following is the most significant risk factor for poor functional outcome?
A) Age at definitive repair B) Associated VACTERL anomalies C) Type of surgical approach (PSARP vs LAARP) D) Duration of colostomy E) Surgeon's experience
Answer: B) Associated VACTERL anomalies 4
Question 4
During a laparoscopic-assisted anorectoplasty (LAARP) for a patient with recto-prostatic urethral fistula, the surgeon encounters difficulty identifying the fistula. What is the most appropriate next step?
A) Convert to open laparotomy B) Defer the procedure and repeat imaging C) Proceed with PSARP approach D) Inject methylene blue through the urethra to identify the fistula E) Place a urethral catheter to help identify the urethra
Answer: D) Inject methylene blue through the urethra to identify the fistula 1, 2
Question 5
A 6-year-old boy who underwent PSARP for high ARM with recto-urethral fistula as an infant now presents with fecal soiling and constipation. Which of the following is the most likely cause?
A) Recurrent fistula B) Anal stenosis C) Inadequate bowel management program D) Sacral anomalies affecting sphincter function E) Neurogenic bladder
Answer: D) Sacral anomalies affecting sphincter function 4, 5
Question 6
A 3-month-old male with high ARM and recto-bulbar urethral fistula is being evaluated for definitive repair. Which of the following statements regarding surgical approach is most accurate?
A) LAARP is contraindicated in all cases of recto-bulbar urethral fistula B) PSARP is associated with significantly better functional outcomes than LAARP C) LAARP is not recommended for bulbar fistula with a long common wall D) Combined laparoscopic and PSARP approach is never indicated E) The choice between PSARP and LAARP has no impact on urologic outcomes
Answer: C) LAARP is not recommended for bulbar fistula with a long common wall 2
Question 7
Following LAARP for high ARM with recto-prostatic urethral fistula, a 6-month-old boy develops high rectal tone. What is the most appropriate initial management?
A) Immediate reoperation B) Botulinum toxin injection C) Intermittent rectal tube insertion D) Permanent colostomy E) Anal dilatation under general anesthesia
Answer: C) Intermittent rectal tube insertion 2
Question 8
A 5-year-old boy who underwent repair of high ARM with recto-urethral fistula presents with recurrent urinary tract infections and urinary incontinence. Urodynamic studies show detrusor overactivity. Which of the following is the most appropriate management?
A) Repeat surgical repair of the fistula B) Clean intermittent catheterization and anticholinergic medication C) Permanent urinary diversion D) Observation only E) Antibiotic prophylaxis alone
Answer: B) Clean intermittent catheterization and anticholinergic medication 5
Question 9
During follow-up of a 2-year-old who underwent LAARP for high ARM with recto-prostatic urethral fistula, rectal mucosal prolapse is noted. What is the most likely contributing factor?
A) Inadequate fixation of the rectum to the pelvic floor B) Excessive intra-abdominal dissection of the rectum C) Urethral diverticulum formation D) Colostomy closure performed too early E) Inadequate anal dilatation
Answer: B) Excessive intra-abdominal dissection of the rectum 2
Question 10
An 8-year-old boy who underwent repair of high ARM with recto-bladder neck fistula as an infant now presents for evaluation of urinary continence. Which of the following factors is most strongly associated with achieving urinary continence in this population?
A) Type of surgical approach used (PSARP vs LAARP) B) Absence of recurrent urinary tract infections C) Absence of associated urethral anomalies D) Age at definitive repair E) Use of bowel management program
Answer: B) Absence of recurrent urinary tract infections 5