when reconstructing an anorectal malformation ( arm ) with posterior sagittal anorectoplasty ( psarp ) , the dissection of the rectourethral fistula is one of the challenges .
the psarp procedure includes opening the rectum posteriorly to clarify the anatomy before dividing the rectourethral fistula.1 the aim of this report is to describe an approach including placing of a guidewire passed through the endoscope in the colostomy , through the fistula to the urethra to facilitate the localization and dissection of the rectourethral fistula early in the operative intervention .
a boy was born in the 38th gestational week , with a birth weight of 2,980 g. on examination , he was found to have an anal atresia without fistula to the perineum .
the boy was provided with a left loop divided colostomy by a laparoscopic approach . at the age of 6 weeks
preoperative colon x - ray examination disclosed the open rectourethral fistula in the distal end of the rectum . before the psarp operation
, an endoscope was inserted through the distal stoma and the fistula to the urethra was identified at the distal end of the rectum .
a guidewire was passed through the endoscope into the fistula and out through the urethra ( figs . 1 and 2 ) .
a catheter was placed into the urinary bladder in the traditional way through the urethra .
video endoscope of 6.5  mm , a guidewire of 2.5  mm , and bladder catheter of 6 charrire were used . 
 through the videoendoscope the rectourethral fistula
is easily identified and a guidewire is passed through the videoendoscope and through the rectourethral fistula . 
 through the endoscope of 9  mm , a guidewire of 2.5
the fistula could initially be shown and dissected without opening the rectum and the guidewire was visualized on opening the distal end of the rectum .
surgical damage to surrounding tissues and intestine was thereby avoided by using this artificial benchmark of the fistula .
no dissection in search of the rectourethral fistula was needed . during the psarp operation ,
the fistula was divided and used for reconstructing the new anus , while the opening to the urinary tract was left without suture.2 
  the postoperative course was uneventful . an x - ray of the urinary bladder and urethra , voiding cystourethrogram , performed 6 weeks later showed a normal urinary tract without any fistula to the bowel .
this case report demonstrates the use of an endoscopy - aided placement of a rectourethral guidewire to facilitate the reconstruction of anus in patients born with arm .
the placement of a guidewire from the distal end of the rectum to the urethra was found to be easy .
a guidewire through the fistula facilitates the dissection and thereby helps avoiding any unnecessary dissection searching for the rectourethral fistula .
the anatomy becomes clearer , and with the wire in place , opening of the intestine during the initial part of the dissection is prevented . by using the guidewire ,
any suspicion of nonexisting fistula could be disregarded through the view from the endoscope . with the video endoscope introduced through the distal stoma , it is usually easy to identify the rectourethral fistula preoperatively .
the risk of damage to the urethra may be reduced and that might lead to fewer problems with urethral stricture or urethral diverticula . with more exact dissection , it is easier to save the tissues in the fistula for reconstruction of the anus .
furthermore , the air in the bowel introduced through the endoscope facilitates the dissection of the blind - ending bowel .
endoscopy - assisted laparoscopic excision of rectourethral fistula in a male patient with imperforate anus has been described without the use of any guidewire.3 by using the method described here , laparoscopy / laparotomy intervention in the abdomen is facilitated . to summarize
since the first time this operative intervention described here was performed , we have used the method in several children with arm with rectourethral fistula , including a child with cloaca . when performing these interventions , we suggest that both options for placing a guidewire through a cystoscopy from the urethra or from a video endoscope from the bowel should be available .
 the aim of this report is to present a technical detail of use in the management of an anorectal malformation ( arm ) . 
 a boy with arm and a fistula to the urethra was operated on with a posterior sagittal anorectoplasty ( psarp ) . before the psarp operation 
 , a videoendoscopy was performed through the distal stoma down to the distal end of the rectum . 
 the rectourethral fistula was identified and a guidewire was passed through the endoscope , through the fistula , and out through the urethra . 
 the endoscopically placed rectourethral guidewire was used as a landmark and facilitated the psarp operation . 
Introduction
Case Report
Discussion