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Rectal cancer following abdomino‐perineal pull‐through for imperforate anus

A 40-year-old man presented with rectal ejaculation, pneumaturia, passive faecal incontinence and 13 kg weight loss. He had undergone a neorectal pull-through operation at the age of 10 months and there was no family history of colorectal cancer. He underwent an examination under anaesthetic (EUA) and endorectal ultrasound (ERUS; Fig. 1a). This demonstrated a clinically fixed anterior tumour, which on ERUS was a locally advanced (T4) neorectal tumour that had fistulated into the base of the urethra. Biopsies taken during EUA confirmed this to be an adenocarcinoma. Both local ERUS and magnetic resonance imaging (MRI) confirmed a bulky neorectal tumour and enlargement of local nodes. Computed tomography (CT) scan demonstrated no metastatic disease. The patient was managed with a defunctioning colostomy and long-course chemo-radiotherapy and planned total pelvic exenteration. Following neoadjuvant treatment he was restaged with repeated CT, CT positron emission tomography (PET), MRI and ERUS findings (Fig. 1b), which demonstrated no significant change in the local disease and no distant metastatic disease. The patient underwent a total pelvic clearance with urinary diversion by ileal conduit reconstruction. The perineal defect (Fig. 1c,d) was filled by a left inferior gluteal artery myocutaneous (IGAM) flap (Fig. 1c,f). He made a good post-operative recovery and was discharged on day 14. Subsequent histological examination demonstrated a ypT4 yN1 tumour and macroscopic malignant invasion of the urethra was confirmed. The circumferential resection margins were clear with the nearest margin at 4 mm. At 12 months follow-up he is well with no evidence of local or distant recurrence.