A High Risk of Urological Diagnosis in Anorectal Malformations

Molly Fuchs, MD
Molly Fuchs, MD, a member of the section of Urology at Nationwide Children’s and part of the surgical team at the Center for Colorectal and Pelvic Reconstruction

PediatricsOnline 

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A recent presentation underscores the importance of consulting urologists in the earliest stages of care.

While there is a general understanding that children with anorectal malformations (ARMs) may have associated urologic diagnoses, a recent report from the Center for Colorectal and Pelvic Reconstruction at Nationwide Children’s Hospital underscores just how critical it is that urologists are involved in the earliest stages of care with these patients.

The study, presented at the Societies for Pediatric Urology Fall Congress in September, had a number of important findings about the correlation of ARM and urological diagnoses:

  • More than 90 percent of female patients with the most complex ARMs (e.g. cloacal malformations with a common channel length > 3 cm) had at least one urological diagnosis, and more than 65 percent had two or more urological diagnoses
  • Almost 70 percent of males with the most complex ARMs (bladder neck fistula) had at least one urological diagnosis, and 50 percent had two or more urological diagnoses
  • Even in comparatively less complex ARMs (perineal fistula), more than half of males and nearly one-third of females had at least one urological diagnosis
  • Severity of ARM is particularly correlated with vesicoureteral reflux and hydronephrosis in all patients

Molly Fuchs, MD, a member of the section of Urology at Nationwide Children’s and part of the surgical team at the Center for Colorectal and Pelvic Reconstruction, was the lead author of the study.

“At many institutions, a child with an ARM may be initially evaluated by a general surgeon, and that surgeon’s focus is appropriately on the colon and rectum,” she says. “What we believed, and what this study has shown, is that there are commonly other organ systems affected by the ARM and the child should have clinicians with expertise in those specialties as part of the initial evaluation.”

The study considered 329 total patients with ARM, with a nearly even split between males and females and a median age of 3.4 years. Vestibular fistula was the most common ARM diagnosis in females and bulbar fistula in males, but a range of ARM complexities was present across the cohort.

At the Center for Colorectal and Pelvic Reconstruction at Nationwide Children’s, urologists are part of the initial evaluation of the child, even before the patient is seen clinically, and they remain involved in the decision-making process for the duration of the child’s care. All patients with ARM should be screened with a kidney ultrasound at least every year, even if providers see little evidence of urological involvement, says Dr. Fuchs.  With evidence, the team will order a more comprehensive workup.

Some institutions may shy away from integrating Urology into ARM diagnoses because of resource concerns, says Marc Levitt, MD, chief of Colorectal and Pelvic Reconstruction at Nationwide Children’s and a co-author of the study. That integration, though, provides optimal care for the patient and can actually save resources. Specialists working together can handle a complex case at once, ultimately saving procedure and inpatient time.

“This kind of collaboration is possible at every institutions, and our study has shown why it is important,” he says.

Reference:

Fuchs M, Sebastiao Y, Weaver L, Farrell N, Halleran D, Ching C, Wood M, Levitt M, Dajusta D. Correlation of anorectal malformation severity and associated urologic abnormalities: a review of 329 patients. Societies for Pediatric Urology Fall Congress; 2018 Sept 14-16; Atlanta, GA.