Delayed surgical management of rectovaginal fistula: a case report highlighting challenges and lessons learned.

Background: Rectovaginal fistulas following an obstetric anal sphincter injury's repair are rare in developed country and their management could be challenging, particularly in cases of delayed repair. This study emphasizes the importance of accurately diagnosing and promptly repairing such fistulas for optimal patient well-being. Case: A 30-year-old patient presented with gas incontinence and a greenish discharge from the vagina, 6 months after delivering her baby. Examination revealed a small pinhole lesion on the posterior vaginal wall, and an endoanal ultrasound confirmed the presence of a rectovaginal fistula. Surgical repair was delayed for 9 months due to the patient's breastfeeding. The fistula was eventually repaired through a transrectal approach, with excision of the fistulous tract and closure of both the rectum and vagina. A laparoscopic protective ileostomy was also performed due to the delayed repair. However, a recurrence of the fistula was detected 8 months later, requiring a second repair. The patient underwent physiotherapy for the anal sphincter and achieved optimal sphincter function. After 6 months, the ileostomy was successfully closed, and the patient remained continent. Conclusions: This case highlights the importance of early recognition and prompt repair of rectovaginal fistulas following obstetric anal sphincter injury. Delayed repairs pose greater challenges and increase the risk of recurrence. Individualized surgical approaches, skilled pelvic floor repair, and a multidisciplinary approach are crucial for successful outcomes. This case underscores the need for careful planning and consideration of patient characteristics in the management of rectovaginal fistulas, aiming to achieve optimal outcomes and patient well-being.

Sigmoid neovagina prolapse treated with Altemeier procedure: case report and systematic review of the literature.

BACKGROUND: Bowel vaginoplasty is a surgical method for neovagina construction that, despite its advantages over other techniques, is still burdened by complications such as prolapse. The incidence of sigmoid neovagina prolapse (SNP) is difficult to determine, and there are no evidence-based recommendations for treatment. We present a case of SNP and a systematic review of previous cases. CASE: A 73-year-old woman presented with stage III prolapse of her sigmoid neovagina constructed 51 years prior. Dynamic pelvic MRI revealed that the majority of the prolapse was due to the mucosa's loss of support. Due to the presence of numerous pelvic adhesions, an alternative to the laparoscopic approach was evaluated by a multidisciplinary team which led to the patient being treated using a modification of Altemeier's procedure. SYSTEMATIC REVIEW: After PROSPERO Registration (CRD42023400677), a systematic search of Medline and Scopus was performed using specific search terms. Study metadata including patient demographics, prolapse measurements, reconstruction techniques, recurrence rates, and timing were extracted. Fourteen studies comprising 17 cases of SNP were included. Vaginal resection of the redundant sigmoid, comprising Altemeier's procedure, was the most definitive surgery, but it was also associated with recurrences in three cases. Laparoscopic sacropexy was the second most definitive surgery with no recurrence reported. CONCLUSION: Our review shows that the recurrence after correction of sigmoid neovagina prolapses is higher than previously reported. Laparoscopy colposacropexy appeared to be the best approach, but it's not always feasible. In these scenarios, a mucosal resection using the Altemeier's procedure is the most effective surgery.

The influence of the fundal pressure manoeuvre at delivery on the anal sphincter injury diagnosed with endoanal ultrasonography.

OBJECTIVES: The fundal pressure manoeuvre (FPM) is a procedure where the fundus of the uterus is pushed through the abdominal wall by the midwifes and doctors to shorten the terminal phase of the second stage vaginal delivery. Nowadays its use is controversial and associated with many adverse effects. The aim of the study was to evaluate benefits and adverse maternal outcomes after FPM. The correlation of the FPM with episiotomy was evaluated. The role of the FPM on pelvic floor dysfunction such as anal incontinence due to anal sphincter injury was assessed. STUDY DESIGN: The retrospective study was conducted between 2017 and 2021. The women who came to the postpartum examination to Gynaecology department for various reasons and gave vaginal birth to a singleton were included in the study. The women who had instrumental delivery were excluded. Minimal sample size was calculated with calculator.net and set on 45. Two groups were formed one with fundal pressure and one without, 96 and 90 patients respectively. The maternal, fetal, and obstetric factors that could be associated with the application of FPM were examined. The endoanal ultrasound examination was performed on all women included in the study. RESULTS: The study did not show that FPM would lead to a more frequent occurrence of anal sphincter injury (p = 0.73), effect its location (p = 0.77) and depth (p = 0.97), however the test group tended to have longer ruptures compared to control group (p = 0.1). No statistically significant differences in episiotomies between control and test group (p = 0.075) were shown. Endoanal ultrasound showed discrepancy between clinically stated and ultrasonographical diagnoses of anal sphincter injuries. In 61,3% of patients with anal sphincter injury after FPM, reported one of the anal incontinence problems of varying degrees six months after delivery. CONCLUSION: Given that the study proved that FPM is not correlated to the anal sphincter injury it can be used safely. The FPM should be performed carefully and only if necessary to safely finish the labour or in combination with instrumental delivery.

Office hysteroscopy in removing retained products of conception - a highly successful approach with minimal complications.

Data of 101 patients with retained products of conception (RPOC), treated with office hysteroscopy (OH) from 2012 to 2015 at the University Medical Centre Ljubljana were analysed. Patients with >30 mm RPOC thickness or strong vascularisation on ultrasound (US) were excluded. Procedures were successfully completed in 94/101 (93%). Mean duration was 18 min (4-60), patient pain estimation with VAS was 2.3 (0-8). No intraoperative complications > Grade II according to Clavien-Dindo classification occurred. Uncompleted cases were safely referred to procedures in general anaesthesia. Follow-up after one month was performed in 78/101 (77%) patients with OH (69) or US (9). Only three patients reported endometritis, three cases of intrauterine adhesions were related to curettage or pre-existing adhesions. We compared preoperative findings of completed and uncompleted cases. Larger size of RPOC and the presence of irregular tissue-myometrial border on US was statistically significantly higher in uncompleted OH (p<.05); mild vascularisation and ß-hCG levels up to 80 U/L did not affect the outcome.Impact statementWhat is already known on this subject? In the last three decades research has focussed on comparing hysteroscopic resection (HR) to traditional dilation and curettage in removing retained products of conception (RPOC). Office hysteroscopy (OH) without hospitalisation or general anaesthesia enables women to return to their daily routine immediately (especially desired by breastfeeding mothers) and is used where available, yet there is little published data to evaluate its role in the management of RPOC.What do the results of this study add? To the best of our knowledge, this article is unique in addressing success, safety and possible limiting factors of OH in removing placental polyps. According to our findings, OH is highly successful (93%), safe, and well tolerated in removing RPOC up to 30 mm in thickness and with no or minimal vascularisation on ultrasound. Thorough follow-up (68% with OH, 9% with US after 1 month) adds to strength of data.What are the implications of these findings for clinical practice and/or further research? Removing large and vascularised RPOC can be a very demanding procedure, yet a majority of patients might benefit from an outpatient approach. Prospective studies on limiting factors and more data on long term reproductive outcomes are needed to fully compare OH to other methods of removal.

Obstetric risk factors for early-onset anal incontinence.

PURPOSE: The aim of the study was to identify primiparous pregnant women with a higher risk for early anal incontinence (AI) after labour. METHODS: In the retrospective case control study, 133 primiparous women were questioned using the Wexner scoring system, and possible obstetric anal sphincter injuries (OASIS) were assessed using endoanal ultrasonography (EUS) 6-12 weeks after the labour. Obstetric characteristics (possible risk factors) for AI were collected from the maternal medical records. The univariate and multiple regression of maternal, neonatal and labour risk factors were calculated. Cut-off values were set to divide women into groups with higher and lower risk for AI. RESULTS: The data of 30 primiparous women with and 103 without AI were analysed. Univariate logistic regression of obstetrics characteristics showed that stimulation of labour (RO [95% CI] 3.31 [1.07, 10.28]) and neonatal head circumference (RO [95% CI] 1.36 [1.03, 1.78]) are both associated with AI. With a neonatal head circumference of 34 cm or more (cut-off value), probability for AI was 33%, while below that value, it was just 2%. The incidence of AI was not significantly different between women with surgically repaired OASIS and women without anal sphincter injury. CONCLUSION: The findings can assist in the identification of pregnant women at higher risk of AI. The women at higher risk of AI should be given special attention during the labour and specific rehabilitation after the labour.

Ultrasound-guided embryo transfer: summary of the evidence and new perspectives. A systematic review and meta-analysis.

Despite the purported advantages of ultrasound guidance during embryo transfer, and the large number of clinical trials published on this topic, recommendations for the use of this technique in daily clinical practice are still under debate. We designed a meta-analysis based exclusively on evidence from published randomized controlled trials, with the aim of analysing the effect of trans-abdominal ultrasound guidance during embryo transfer versus clinical touch and of transvaginal ultrasound guidance (TV-US) versus the trans-abdominal approach on IVF outcomes. On the basis of 14 randomized trials, we found a moderate quality of evidence supporting the beneficial effects of transabdominal guidance during embryo transfer compared with conventional clinical touch in clinical pregnancy and ongoing or live birth rates. No significant differences were found in miscarriage and ectopic pregnancy rate, with low or very low quality of evidence, respectively. On the basis of three randomized trials, we found the quality of evidence supporting the equivalence of transvaginal versus transabdominal approach in clinical pregnancy and ongoing or live birth rates to be low. Finally, larger randomized controlled trials are necessary to explore the possible benefits of TV-US, three-dimensional ultrasound imaging modality, and uterine length measurement before transfer.

Could the correct side of mediolateral episiotomy be determined according to anal sphincter EMG?

INTRODUCTION AND HYPOTHESIS: Mediolateral episiotomy is one of the most frequent surgical interventions performed in obstetrics. There is conflicting evidence as to whether mediolateral episiotomy reduces the risk of obstetric anal sphincter injuries (OASI). Recent studies suggest that functional asymmetry of pelvic floor innervation exists in healthy women and is strongly associated with postpartum incontinence when the trauma occurs on the dominant side of innervation. Mediolateral episiotomy is the most common cause of perineal trauma during delivery, and the surgical incision is usually performed on the mediolateral right side. Surface electromyography (EMG) has been recently applied in obstetrics for detecting electrical activity of the external anal sphincter (EAS). METHODS: Two hundred and forty-five pregnant nulliparous women at their second and third trimester of pregnancy were recruited, and EMG signals were detected using a multichannel cylindric anal probe. Measurements were repeated and compared 6-8 weeks after delivery on a subgroup of 167 women who were divided in two groups according to EMG amplitude asymmetry before delivery and two subgroups according to type of delivery: (1A) asymmetric left, episiotomy right; (1B) asymmetric left, other types of deliveries; (2A) asymmetric right, episiotomy right; (2B) asymmetric right, other type of deliveries. RESULTS: The reduction of EMG amplitude after right episiotomy was larger in women with right asymmetric sphincter compared with women with left asymmetry and women with other types of delivery. CONCLUSIONS: Prenatal EMG may be used to predict the impact of right-sided mediolateral episiotomy on EAS and perhaps also function following delivery.

Impact of mediolateral episiotomy on incidence of obstetrical anal sphincter injury diagnosed by endoanal ultrasound.

OBJECTIVE: to examine potential association between mediolateral episiotomy and reduced incidence of obstetrical anal sphincter injuries (OASIS) diagnosed by endoanal ultrasound. DESIGN: prospective cohort study. SETTING: tertiary referral university hospital. PARTICIPANTS: sixty nulliparous women at 28-33 weeks of gestation with singleton pregnancies were included between 2010 and 2012. MEASUREMENTS AND FINDINGS: participants were examined with endoanal ultrasound at 28-33 weeks gestation and at 6-7 weeks post-partum. At both visits, symptoms of anal incontinence were assessed using Cleveland Clinic (Wexner) faecal incontinence scoring system. Mann Whitney U-test and χ2 test was used to compare groups with vs. without episiotomy and groups with vs. without OASIS diagnosed by ultrasound. χ2 test was used to assess correlation between OASIS and anal incontinence symptoms (p≤0.05 considered significant). None of the women included had sphincter injury or anal incontinence before childbirth. All delivered vaginally. Mediolateral episiotomy was performed in 33 (55%) cases. Six (10%) had OASIS on endoanal ultrasound (two were also diagnosed clinically), and 11 had symptoms of anal incontinence post-partum. No significant differences were seen in clinical characteristics between groups with vs. without episiotomy. No significant differences were seen in episiotomy rate (p=0.14), angle (p=0.42) and length (p=0.14) between groups with vs. without OASIS on ultrasound. Correlation between anal incontinence symptoms and sonographically diagnosed OASIS was statistically significant (p=0.04). KEY CONCLUSIONS: mediolateral episiotomy does not seem to be protective against clinically or sonographically diagnosed OASIS even when episiotomy technique is considered. Endoanal ultrasound allows a significantly better detection of symptomatic OASIS compared to clinical examination alone. IMPLICATIONS FOR PRACTICE: mediolateral episiotomy should be considered only when shortening the second stage of labour is indicated due to foetal distress, and not as a means of OASIS prevention.

Can we predict obstetric anal sphincter injury?

OBJECTIVE: The aim of the study was to identify primiparous pregnant women with a higher risk for obstetric anal sphincter injuries (OASIS) based on obstetric characteristics (risk factors). STUDY DESIGN: In the retrospective case control study primiparous women were examined using endoanal ultrasonography (EUS) for OASIS identification 6-12 weeks after delivery. Obstetric characteristics for OASIS were collected from the mothers' medical records. The univariate analysis of maternal (age at delivery, maternal height, weight, BMI), infant (length, weight and head circumference) and birth (pregnancy duration, labour and delivery duration, episiotomy, vacuum extraction and oxytocin augmentation) risk factors, Pearson correlations and information gain were carried out. The cut-off values for the aforementioned risk factors divided the patients into groups with higher and lower risk of OASIS. RESULTS: The data of 84 primiparous women with OASIS, and 58 without, were analysed. Those newborns born to women in the OASIS group were heavier (P<0.05), with the cut-off at 3420g (72% probability of OASIS), had a larger head circumference (P<0.001), cut-off at 36cm (84% probability of OASIS), and were longer (P<0.05), cut-off at 50.5cm (74% probability of OASIS). The maternal age and body mass index (BMI) were risk factors for OASIS (P<0.05 and P<0.05, respectively) with a probability of 83% in women younger than 27.5 years and a 78% probability if BMI was higher than 28kg/m2. The incidence of OASIS was not higher in women with episiotomy or vacuum extraction, but it was higher in oxytocin augmentation (P<0.031). CONCLUSION: The findings can assist in identification of pregnant women with a higher risk of OASIS who require special attention at delivery to prevent it. In high risk women EUS is indicated to identify and treat possible OASIS as early as possible in order to prevent anal incontinence.

Effect of vaginal delivery on the external anal sphincter muscle innervation pattern evaluated by multichannel surface EMG: results of the multicentre study TASI-2.

INTRODUCTION AND HYPOTHESIS: A correlation exists between external anal sphincter (EAS) damage during birth and the subsequent development of fecal incontinence. This study evaluated the effect of delivery-related trauma on EAS innervation by means of intra-anal EMG performed with a rectal probe with 16 silver electrodes equally spaced along the circumference, before and after delivery. METHODS: Pre-partum EMG measurements were performed on 511 women, by nine clinical partners from five European countries at the 28th to 34th gestational weeks and the 6th to 8th post-delivery weeks; 331 women returned, after delivery, for the second test. The innervation zones (IZ) of EAS single motor units were identified by means of an EMG decomposition algorithm. RESULTS: The subjects were divided into four groups according to the delivery mode (Caesarean, vaginal with no evident damage, spontaneous lacerations and episiotomies). The number of IZs before and after delivery was compared. In the 82 women who underwent right mediolateral episiotomy, a statistically significant reduction of IZs was observed, after delivery, in the right ventral quadrant of the EAS (side of the episiotomy). Women who had Caesarean section, spontaneous lacerations or lack of evident damage did not present any significant change in the innervation pattern. CONCLUSIONS: Right episiotomy reduces the number of IZs on the right-ventral side of the EAS. The fast and reliable test proposed indicates the sphincter innervation pattern before delivery and helps obstetricians to evaluate the risks and to choose the preferred side of the episiotomy, if deemed necessary at the time of delivery.

Characterization of the motor units of the external anal sphincter in pregnant women with multichannel surface EMG.

INTRODUCTION AND HYPOTHESIS: Locating the innervation zones (IZs) of the external anal sphincter (EAS) is helpful to obstetricians to identify areas particularly vulnerable to episiotomy in pregnant women. The aim was to investigate the motor unit (MU) properties of the EAS during voluntary contractions. METHODS: Electromyographic signals were detected, from 478 pregnant women, by means of an intra-anal cylindrical probe carrying a circumferential array of 16 electrodes. The signals were decomposed into the constituent MU action potential trains and 5,947 templates were extracted and analyzed in order to identify the IZ position. RESULTS: MUs innervated at one end are concentrated in the dorsal portion of the sphincter, while MUs innervated in the middle are distributed symmetrically in the left and right portions of the EAS. The angular propagation velocity was estimated for each MU resulting in 260 ± 45 rad/s, corresponding to 1.8 m/s on the probe surface and to about 4 m/s at a radial depth of 10 mm from the probe surface. CONCLUSIONS: A novel method for identification and classification of MUs of the EAS is proposed and applied to a large-scale study. It is possible to distinguish MUs of the EAS in a minimally invasive way and identify their IZs. This information should be used to plan episiotomies and minimize risks of EAS denervation.