Construction of female urethra from vaginal wall and a perineal flap.

Five incontinent girls between 4 and 18 years old were made continent by constructing in each case a long extension of the urethra up to the clitoris. Previous operations at the proximal end of the urethra, to narrow the bladder neck, had not achieved continence. Lengthening the urethra was accomplished by tubularizing the anterior vaginal wall and covering that with a generous pedicle flap from the perineum. The base of the pedicle flap was divided later, restoring the introitus to a normal appearance. Of the 5 patients 3 had the underlying problem of ureteral ectopia with congenital deficiency of the urethra and the bladder neck, 1 had a marked degree of female hypospadias with absence of the distal urethra and in 1 the cause for incontinence was extensive internal urethrotomy during early childhood. This procedure should be applicable to certain difficult cases of incontinence in pediatric and adult patients.

A clinical evaluation of the surgical treatment of anorectal malformations (imperforate anus).

The surgical correction of anorectal malformations remains a serious problem despite their relatively frequent occurrence. Our surgical experience with 90 patients, seen in the past ten years, includes abdominal-perineal or sacro-abdominal-perineal repair in 28 patients, complete perineal anoplasty in 13 patients, and "cut-back" perineal anoplasty in 38 patients. Secondary surgical procedures for "fecal reservoir syndrome" (seven patients), revision for stricture (11 patients) and excision of redundant mucous membrane (ten patients). The observations made from this clinical study are: 1) The importance of thorough urological and neurological evaluation of "high" abnormalities and the value of the cremasteric and bulbocavernosus reflexes as indicators of sacral innervation. 2) Increasing satisfaction with the "cut-back" anoplasty as a definitive procedure or as a temporary stage in low recto-vaginal or recto-vestibular fistulas. The technique for the "cut-back" is improved by the use of Burow's triangles and the use of nonabsorbable sutures. 3) The advisability of the complete perineal anoplasty with posterior positioning of the anus and construction of a perineal body in patients with low recto-vaginal and recto-vestibular fistulas. 4) A concern over the functional capacity of the distal bowel segment in high abnormalities. This is emphasized by the experience with six secondary resections of the rectosigmoid or left colon for "fecal reservoir syndrome." 5) Heartening results with secondary operations for stricture and redundant mucous membrane which suggest the desirability of an earlier surgical approach to these complications.