Indications and outcomes of enterovesical and colovesical fistulas: systematic review of the literature and meta-analysis of prevalence.

BACKGROUND: Entero-colovesical fistula is a rare complication of various benign and malignant diseases. The diagnosis is prominently based on clinical symptoms; imaging studies are necessary not only to confirm the presence of the fistula, but more importantly to demonstrate the extent and the nature of the fistula. There is still a lack of consensus regarding the if, when and how to repair the fistula. The aim of the study is to review the different surgical treatment options, focus on surgical indications, and explore cumulative recurrence, morbidity, and mortality rates of entero-vesical and colo-vesical fistula patients. METHODS: A systematic review of the literature was conducted according to PRISMA guidelines. Random effects meta-analyses of proportions were developed to assess primary and secondary endpoints. I2 statistic and Cochran's Q test were computed to assess inter-studies' heterogeneity. RESULTS: Twenty-two studies were included in the analysis with a total of 861 patients. Meta-analyses of proportions pointed out 5, 22.2, and 4.9% rates for recurrence, complications, and mortality respectively. A single-stage procedure was performed in 75.5% of the cases, whereas a multi-stage operation in 15.5% of patients. Palliative surgery was performed in 6.2% of the cases. In 2.3% of the cases, the surgical procedure was not specified. Simple and advanced repair of the bladder was performed in 84.3% and 15.6% of the cases respectively. CONCLUSIONS: Although burdened by a non-negligible rate of complications, surgical repair of entero-colovesical fistula leads to excellent results in terms of primary healing. Our review offers opportunities for significant further research in this field. Level of Evidence Level III according to ELIS (SR/MA with up to two negative criteria).

Delayed recognition of lower urinary tract injuries following hysterectomy for benign indications: A NSQIP-based study.

OBJECTIVE: To describe the incidence of and factors associated with lower urinary tract complications recognized in the immediate postoperative period following hysterectomy for benign gynecologic indications using the NSQIP (National Surgical Quality Improvement Program) database. METHODS: Patients who underwent hysterectomy for benign indications from 2014 through 2016 were identified in the NSQIP database using Current Procedural Terminology codes and International Classification of Diseases codes. Patient demographics, preoperative comorbidities, ASA classification system scores, and total operating time were collected. Data on 30-day postoperative complication rates, including rates of reoperation and readmission, were also captured. Genitourinary complications were defined as ureteral obstruction, ureteral fistula, and bladder fistula. RESULTS: A total of 45,139 patients met inclusion criteria during the study period. Mean age and body mass index were 31 ± 11years and 32 ± 8 kg/m2. The majority of patients were white (66%), had an ASA class of 2 (67%), and had no major medical comorbidities (68%). The most commonly performed primary surgery was laparoscopic hysterectomy (43%), followed by abdominal hysterectomy (27%). The incidence of any lower urinary tract complication was 0.2% (95% confidence interval, 0.19-0.28): 55 ureteral obstructions (0.1%, 95% confidence interval, 0.09-0.16), 33 ureteral fistulae (0.07%, 95% confidence interval, 0.05-0.1), and 28 bladder fistulae (0.06%, 95% confidence interval, 0.04-0.09). In a multivariable logistic regression model, black race (adjusted odds ratio, 1.90; 95% confidence interval, 1.20-2.96), endometriosis (adjusted odds ratio, 2.29; 95% confidence interval, 1.44-3.52), and prior abdominal surgery (adjusted odds ratio, 1.53; 95% confidence interval, 1.01-2.28) remained significantly associated with the occurrence of any lower urinary tract complication recognized in the immediate 30-day postoperative window. CONCLUSION: Lower urinary tract complications recognized in the immediate postoperative period following hysterectomy for benign gynecologic disease are rare, with ureteral obstruction being the most commonly reported complication. The risk of these complications may be higher in patients who identify as black, had prior abdominal surgery, and/or have a diagnosis of endometriosis.

[Surgical management of entero-vesical fistulas in Crohn's disease]. / Traitement chirurgical des fistules entéro-vésicales secondaires à la maladie de Crohn.

BACKGROUND: Crohn's disease (CD) is a chronic inflammatory disease of the intestine that can cause an attack by contiguity of the urinary tract. Although the shape is common and fistulizing 35% of all patients with CD, entero-urinary fistulas are rare and only seen in 2-8% of patients. aim: To report the frequency of occurrence of this complication among the group of surgical forms of CD. Describe the different pathophysiological mechanisms of occurrence of entero-vesical fistula (EVF) during the CD. methods: We report, retrospectively, seven observations of EVF complicating MC made during the period from 01/01/1998 until 31/12/2010. results: The mean age of patients was 30 years. There were 3 men and 4 women. All patients had clinical signs and radiological EVF. In six patients, CD was ileo-caecal and the ileo-vesical fistula was between the last loop and the bladder. In one patient, the CD was located only in colon, and the fistula was between sigmoid colon and bladder. Level of the bladder, it was a false EVF in five patients and a true EVF in two patients. In these last two, the fistula of 2 mm, was on the top of the bladder. Treatment consisted in all cases by a disconnect between the digestive tract and bladder, resection with restoration of digestive continuity, and if the case of true EVF, a freshening the edges of the fistula with suture of the bladder's wall and drainage. The postoperative course was uneventful in six patients and marked by an outbreak intraperitoneal abcess in one patient who had evolved under medical treatment. After a mean of eleven months, no recurrence surgery was noted. CONCLUSION: Despite advanced treatment in the context of CD, the indication in EVF is a surgical treatment. Surgery helps fight against the consequences of septic urinary tract, but also to launder bowel disease and reduce the risk of recurrence in the short term.

Vesicoureteral reflux and febrile urinary tract infections in anorectal malformations: a retrospective review.

BACKGROUND: Multiple studies document a correlation between anorectal malformations (ARMs) and vesicoureteral reflux (VUR), development of urinary tract infections (UTIs), and subsequent renal disease. We aimed to determine which patient characteristics are associated with VUR and UTI in this population. METHODS: A retrospective review of ARM patients at a free-standing children's hospital from January 1996 to December 2011 was performed. Logistic regression was used to investigate the associations between VUR and UTI and ARM classification and co-morbid diagnoses. RESULTS: Of 190 patients, 41 (31%) received a diagnosis of VUR. Thirty-one of the 190 patients had at least one febrile UTI (16%). Of these, only 16 (51%) had a diagnosis of VUR. On multivariable logistic regression, the only patient variable associated with VUR was having an ectopic kidney (p=0.026). Similarly, the presence of GU malformations was the closest variable associated with developing a UTI (p=0.073). CONCLUSIONS: In ARM patients, VUR as well as UTIs are associated with the presence of GU malformations. Thus, voiding cystourethrogram (VCUG) testing should be pursued when there are other caudal and GU abnormalities, regardless of fistula location. Antibiotic prophylaxis for UTI should be considered in children with ARM and any GU malformation, not only VUR.

Vesicouterine fistulae: our experience of 17 cases and literature review.

AIM: A retrospective study of vesicouterine fistulae managed from 1996 to 2011 analyzed the incidence, symptomatology, diagnosis, and surgical outcome. PATIENTS & METHODS: During the study period, 17 patients were managed, of whom 14 underwent abdominal repair and three underwent vaginal repair. Mean patient age was 31.1 years and mean follow-up 7.3 years. RESULTS: Vesicouterine fistulae resulted following cesarean section in 13 patients and vaginal delivery in four. Eleven patients presented with urinary leakage via the vagina and seven with menouria. All patients had successful outcomes irrespective of treatment approach. The uterus was conserved in ten patients, of whom seven had completed their childbearing. The remaining three conceived spontaneously and underwent elective cesarean section. CONCLUSION: The majority of vesicouterine fistulae occur following cesarean section, and it is feasible to achieve 100 % successful repair. Though the majority require abdominal repair, a few selected cases can be successfully repaired vaginally.

Urogenital fistula in a Saudi Arabian referral center.

PURPOSE: To review all cases of genitourinary fistula, their causes, management and outcome. MATERIALS AND METHODS: A retrospective chart review of all fistula cases referred to the Urogynecology Department, King Fahad Medical City, Riyadh, Saudi Arabia, from January 2005 to December 2011. RESULTS: Sixteen genitourinary fistula cases were identified; nine (56 %) cases of vesicovaginal fistula, four (25 %) cases of vesicouterine fistula, and three (19 %) cases of vesicocervical fistula. Mean age was 41 (29-61) and mean parity was 7.4 (2-15). Out of the 16 cases, 12 (75 %) had obstetrical surgical complications, of which 8 (50 %) had complications of cesarean sections. Twelve of 15 cases (80 %) were cured after primary surgical repair, 2 (13 %) after secondary repair and 1 after tertiary repair. One case was cured after conservative management. CONCLUSION: Most of the genitourinary fistulae were of iatrogenic obstetric causes, mainly cesarean section with none of the cases due to obstructed labor unlike fistulae in developing countries or developed countries fistulae (iatrogenic gynecologic origin).

Urinary tract fistulas in radical surgery for cervical cancer: the importance of early diagnosis.

BACKGROUND: Urinary fistulas are a well-recognised complication of radical gynaecological oncology surgery for cervical cancer. Reported incidence varies between 0.6 and 5.1%. METHODS: A retrospective case-note review of vesical and ureteric fistulas diagnosed in cases that underwent radical surgery for the new diagnosis of early stage cervical cancer between January 2000 and June 2010. RESULTS: A total of 323 radical procedures for cervical cancer were performed during the study period. There were nine urinary tract fistulas found in eight women undergoing radical surgery for stage 1b1 cervical cancer, giving an incidence of 2.7%. Haemorrhage was the commonest associated factor and the commonest presenting symptom for fistula was leaking of urine per vagina. The fistulas were managed conservatively or surgically depending on their nature and severity. The longer the delay in confirming the diagnosis and initiating treatment the more severe were the long-term symptoms and morbidity. CONCLUSION: Identification of predisposing factors, high index of suspicion, early investigations and multidisciplinary team management of urinary tract fistula are necessary to reduce post-operative morbidity and minimise renal loss.

Cesarean delivery-related fistulae in the Democratic Republic of Congo.

OBJECTIVE: To compare the characteristics of urogenital fistulae after cesarean delivery with those after spontaneous vaginal delivery. METHODS: A retrospective analysis of hospital records of 597 consecutive patients with a urogenital fistula who received treatment at Panzi Hospital, Bukavu, Democratic Republic of Congo, during 2005-2007. RESULTS: Of 576 women with an obstetric fistula, 229 (40%) had had a cesarean delivery; 55 (24%) of the 229 fistulae were considered to be iatrogenic. The distribution of risk factors (age, stature, parity, and labor duration) was similar to that among 226 women with a spontaneous vaginal delivery, but the odds ratios for having a ureterovaginal or a vesicouterine fistula were 11.9 (95% confidence interval [CI] 2.8-51.2) and 9.5 (95% CI 2.8-31.9), respectively. Vesicovaginal fistulae with cervical involvement were also significantly more frequent in the cesarean delivery group. The fistulae in this group had less surrounding fibrosis and there was less treatment delay. Stillbirth rates were 87% (cesarean delivery) and 95% (spontaneous vaginal delivery). CONCLUSION: The data indicate that cesarean delivery-related fistulae are a separate clinical entity. Focus on this condition is important for fistula prevention and provision of adequate obstetric care, particularly for training in surgery and alternative delivery methods.

Colon agenesis with ileovesical fistula and anorectal malformation.

Colonic agenesis is a rare cause of congenital bowel obstruction and is usually associated with other malformations such as abdominal wall defects or gastrointestinal, cardiac, urogenital, and musculoskeletal lesions. Although many uncommon types have been reported, ileovesical fistula (IVF) associated with total colonic agenesis (TCA) has not been reported in a newborn with anorectal malformation (ARM). This is the first report of a 1-day-old newborn with ARM, IVF, and TCA.

[Incidence, diagnosis and treatment of colovesical fistula]. / Incidencia, diagnóstico y tratamiento de la fístula colovesical.

BACKGROUND: Enterovesical fistula, also known as vesicoenteric fistula, is an abnormal communication of the vesical bladder with a segment of the digestive tract. We undertook this study to describe diagnostic and therapeutic methods to treat colovesical fistula (CVF) in patients who attended the Coloproctology Unit of the Gastroenterology Service of the General Hospital in Mexico City. METHODS: This is a descriptive study in CVF patients carried out from January 2001 to June 2006; descriptive statistics were used for analysis of information. RESULTS: Eleven patients were identified (10 males and 1 female). Average age was 54.72 years (range: 39-73 years). Time from onset of symptoms to diagnosis was on average 11.9 months. The most frequent signs and symptoms were fecaluria, pneumaturia, dysuria, hematuria and chronic abdominal pain in hypogastric and left iliac regions. Nine patients were submitted to sigmoidectomy and primary colorectal anastomosis. Hartmann procedure was carried out in one patient with restoration of intestinal transit 6 weeks later. In one patient, a loop colostomy was built as a first operation, with sigmoidectomy with fistula resection as a second operation, and restoration of intestinal transit as the third. CONCLUSIONS: Surgery is the only treatment that assures cure and avoids relapses. Sigmoidectomy and primary anastomosis must be considered as the treatment of choice. Mortality, although low, continues being a negative factor when surgery is indicated in these patients.

Genital fistula--our experience.

Genital fistulas cause immense physical and psychosocial problem in women's life. The present study was conducted to note the varieties of genital fistula as well as their causative factors and the results of the operative corrections. Altogether 42 patients with different varieties of genital fistula were enrolled in the study. The causative factors of the genital fistulas, specially, that of vesicovaginal fistulas were thoroughly enquired. After confirming the diagnosis, the operative corrections were undertaken. Among the varieties of genital fistula, 76.19% were vesicovaginal fistula, 11.90% were rectovaginal fistula and 4.76%, 4.76% and 2.38% cases of ureterovaginal, urethrovaginal and vesicocervical fistulas respectively. The primipara women were the major sufferers of genital fistulas due to obstetric grounds. Regarding aetiologies of vesicovaginal fistulas, 71.87% patients had obstetric reasons, after prolonged labour, instrumental delivery and after caesarean section due to obstructed labour. Abdominal hysterectomy (44.44%) topped the list of the gynaecological causes of vesicovaginal fistulas. The cases of ureterovaginal fistulas were after abdominal hysterectomy. One case of urethrovaginal fistula was due to some chemical application for correction of genital prolapses. The rectovaginal fistulas were mostly due to obstetric reasons. The success rate after the first attempt of repair of vesicovaginal fistula was 82.75% and overall failure was 10.34%. The other varieties of fistulas were repaired with 100% success rate. The incidence of genital fistulas can be reduced by vigilant obstetric care and meticulous surgery.

Are perineal and luminal fistulas associated in Crohn's disease? A population-based study.

BACKGROUND & AIMS: We aimed to determine the frequency of fistulizing Crohn's disease (CD) and the relationship between perineal and luminal fistulas. METHODS: A population-based retrospective study was conducted by using the University of Manitoba Inflammatory Bowel Disease Research Registry. In 2003 there were 3192 IBD patients, 1595 had (CD), and 398 patients reported stricturing or fistulizing disease. Patients were interviewed and medical records were reviewed for phenotype assessment. Perineal fistulas were defined as those exiting in the perineum or fistulizing to sexual organs. Luminal fistulas were defined as arising from the bowel to organs other than the perineum. RESULTS: The prevalence of fistulizing CD was at most 22.1%. Of the 398 patients, 280 CD patients were eligible for full phenotype verification. Of these, 50 patients had both perineal and luminal fistulas, 151 had only perineal fistulas, and 79 had only luminal fistulas. Odds ratio (OR) for likelihood of having luminal fistula disease if perineal disease was present was 5.02 (95% confidence interval [CI], 3.40-7.42; P < .0001). Fistula patients were more likely to be diagnosed younger; 20-29 years (OR, 1.37; 95% CI, 1.02-1.85; P = .048). Compared with luminal fistulas, perineal fistulas had a higher likelihood to have colonic (OR, 3.32; 95% CI, 1.59-6.90; P = .002) rather than isolated ileal involvement (OR, 0.39; 95% CI, 0.21-0.72; P = .004). The comparison of fistulizing CD to non-fistulizing disease revealed a predisposition to colonic (OR, 1.41; 95% CI, 1.04-1.90; P = .032), ileocolonic (OR, 2.49; 95% CI, 1.91-3.26; P < .001), and upper gastrointestinal (OR, 3.87; 95% CI, 1.93-7.74; P < .0001) disease versus isolated ileal involvement (OR, 0.25; 95% CI, 0.19-0.34; P < .0001). CONCLUSIONS: There is a lower prevalence of fistulizing CD in this population than previously published. Perineal and luminal fistula diseases are highly related to one another but typically have distinct clinical associations.

Pseudomyxoma peritonei and the urinary tract: involvement and treatment related complications.

BACKGROUND: Pseudomyxoma peritonei (PMP) is a rare clinical syndrome characterized by intraperitoneal accumulation of mucus produced by neoplastic cells of mostly appendiceal origin. The aim of this study was to analyze primary and secondary involvement and treatment-related complications of the urinary tract in PMP. METHODS: A retrospective study of 92 patients with PMP, treated by cytoreduction and intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) at The Netherlands Cancer Institute between 1996 and 2004. RESULTS: Seven patients presented with involvement of the urinary tract. Major urologic complications occurred in five patients, of which two had secondary involvement of the urinary tract. Major urologic complications consisted predominantly of surgical complications related to the bladder. All patients with secondary involvement and/or urologic complications had undergone previous pelvic surgery. CONCLUSIONS: The urinary tract is rarely involved in patients with PMP. Secondary involvement is mostly observed and may be a result of seeding of PMP of pelvic origin after prior pelvic surgery. There is a low urologic complication risk of treatment with cytoreduction and HIPEC. The combination of secondary involvement and previous pelvic surgery is an omen of treatment-related urologic complications, necessitating (surgical) re-interventions and further management in close collaboration with urologists.

The spectrum of colovesical fistula and diagnostic paradigm.

BACKGROUND: Our experience with colovesical fistula (CVF) over a 12-year period was reviewed to clarify its clinical presentation and diagnostic confirmation. METHODS: Twelve patients with CVF were identified. Presenting symptoms, etiologic factors, diagnostic investigations, and subsequent treatment were reviewed. RESULTS: Underlying etiologies were diverticular disease (75%), colon cancer (16%), and bladder cancer (8%). Pneumaturia (77%) was the most common presentation, followed by urinary tract infections, dysuria and frequency (45%), fecaluria (36%), hematuria (22%), and orchitis (10%). The ability of various preoperative investigations to identify a CVF were: computed tomography (CT) (90%), barium enema (BE) (20%), and cystography (11%), whereas cystoscopy, intravenous pyelogram (IVP), and colonoscopy were nondiagnostic. All patients underwent single- or multiple-staged repair of the fistula. CONCLUSIONS: In patients with a suspected CVF, we recommend CT followed by a colonoscopy as a first-line investigation to rule out malignancy as a cause of CVF. Other modalities should only be used if the diagnosis is in doubt or additional information is needed to plan operative management.

Obstetric fistula: the challenge to human rights.

Obstetric fistula can be explained to result from different causes. These holes in the tissue wall between the vagina and bladder and/or rectum are most prevalent in resource-poor countries, attributable to prolonged obstructed labour and absent or inaccessible remedial prenatal services. Obstructed labour is often due to small pelvic size, resulting from women's youth and premature childbearing and/or malnutrition. Poverty at national health-service and family levels often predisposes pregnant populations to suffer high rates of fistula. Global estimates showing up to 100,000 new cases each year and 2 million affected girls and women are probably gross underestimates. Fistula devastates lives of sufferers, who are often expelled by husbands and become isolated from their families and communities. Failures of states to provide prenatal preventive care (including medically indicated cesarean deliveries) and timely fistula repair violate women's internationally recognized human rights, especially to healthcare in general and reproductive healthcare in particular.

[Vesico-vaginal fistula: report of 1050 cases]. / Les fistules vésico-vaginales: à propos de 1050 cas.

The authors reports their experience of a large series of 1050 cases of vesico-vaginal fistulas recorded during 30 years and analyse their epidemiological, anatomo-clinical, and therapeutic aspects. Patients could be classified as a function of site of fistula into 3 types, according to the Benchekroun's classification: type I ureto-vaginal fistula (30%); type II cervico-vaginal fistula (22%); type III vesico-vaginal fistula (48%). Etiology was mainly obstetrical (93%). An associated lesion was detected in 10.4% of cases (uterine, ureteral and rectal). Treatment was only performed after a minimal period of three months with the following results in obstetrical vesico-vaginal fistulas. Type I fistula, using a low approach and requiring urethral refection in 100 cases, showed good results in only 60% of cases. Type II fistulae, usually treated through a low approach (80%), were treated with 80% good results. Type III fistula, were nearly always corrected (98%) after two procedures. The overall results are good in 80% of cases. The failures concerned in majority the complex vesico-vaginal fistulas type I, are treated by urinary diversion (51 Coffey, 5 Bricker) and since 1975, 73 continent ileocecal or ileal bladders using Benchekrouns' technique.

Resolución de un síndrome de Youssef mediante tratamiento con análogos de GnRh. Caso clínico. Respuesta

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Vesico-vaginal fistula: experience of 230 cases.

We reviewed 230 cases of vesico-vaginal fistula in Ramathibodi Hospital from 1969 to 1997. The cases of fistula included 164 cases after transabdominal hysterectomies, 5 cases after anterior colporrhaphies, 8 cases after radical hysterectomy, 23 cases after vaginal hysterectomy, 10 cases after prolonged or traumatic birth, 9 cases after radiation for cervical carcinoma, 7 cases of cervical cancer invasion, 2 cases after suprapubic cystolithotomy and 2 cases after pelvic fracture. Most of them were referred from other hospitals. In 7 cases, the fistula closed spontaneously after indwelling urethral catheters for 4-6 weeks. Five cases were cured after transurethral fulgurations. The rest were treated with different surgical procedures i.e. transvaginal, transvesical and retrovesical repairs. Ten cases were treated by urinary diversions, usually after failure using other surgical procedures.

Spontaneous closure of vesicouterine fistula. Account for effective hormonal treatment.

OBJECTIVES: To analyze the incidence of spontaneous closure, or non-surgical resolution, of vesicouterine fistula and discuss the resultant implications for the management. METHODS: Review of the literature supplemented by case report of a young woman with spontaneous healing of vesicouterine fistula. RESULTS: This is the 41st patient with spontaneous closure of vesicouterine fistula reported to date. Her clinical course was suggestive of endocrine involvement in the lesion's formation. Spontaneous healing was observed in 5% of 796 vesicouterine fistula cases. Induction of amenorrhea was effective in 8 (89%) of the 9 patients treated, a rate significantly higher (p < 0.001) than that observed without hormonal manipulation (4%). CONCLUSIONS: Conservative management by means of hormonal treatment should be considered before surgical repair. We suggest the role of estrogens and the endometrium in the formation of vesicouterine fistulas.

Analysis of 1,992 patients with anorectal malformations over the past two decades in Japan. Steering Committee of Japanese Study Group of Anorectal Anomalies.

BACKGROUND/PURPOSE: This report describes the results of a group study of the Japanese Study Group of Anorectal Anomolies (JSGA) to determine the relative incidence of specific types of anorectal anomaly in Japan, and includes discussion of rectourethral fistula regarding the relationship between the levels of the fistula and blind end of the rectum, low type deformity, rare types, and associated anomalies. METHODS: A total of 1,992 patients (1,183 boys and 809 girls) registered from 1976 to 1995 were analyzed. RESULTS: High-type deformities accounted for 26.0% of cases, intermediate 10.7%, low 57.2%, miscellaneous 4.5% and unclassified 1.8%. The most frequent deformity was male anocutaneous fistula (n = 364), followed by male rectourethral fistula (n = 333), and female anovestibular fistula (n = 241). There were 42 rectovesical fistulas in boys and 93 rectocloacal fistulas in girls. Covered anus complete occurred at the same frequency (10.1% of low deformities) as covered anal stenosis. In rectourethral fistula, the blind end of the rectum lay at or above the level of the P-C line in 40.3% of cases, at or above the M line in 39.6% and at the vicinity of the I line in 20.2%, respectively. There was no parallel relationship between the site of the fistula opening and the level of the rectal pouch. The overall incidence of patients having one or more associated anomalies was 45.2%: 70.6% in high deformity, 60.7% in intermediate, and 31.3% in low. The rate of association of Down's syndrome with deformities without fistula (40.3%) was significantly higher than with deformities with fistula (0.3%). CONCLUSIONS: Rectovesical fistula and covered anus complete were not infrequent deformities in this series. We consider that at least 20% of rectourethral fistula should be categorized as intermediate or low deformity from the viewpoint of the position of the rectal pouch. A significant preponderance of Down's syndrome in the deformities without fistula suggests that further investigation of associated anomalies in comparision with other congenital diseases may provide insights into the pathogenesis of anorectal malformation in the field of molecular genetics.