Combined clinical and radiological remission of rectovaginal fistulas using fractional CO2 vaginal laser: a case series and medium-term follow-up.

INTRODUCTION: Despite the advances in surgical and clinical approaches, there is no consensus regarding the best line of treatment from rectovaginal fistula (RVF). Faced with a challenging scenario in the approach of RVF, the fractional CO2 laser receives attention as a possible form of treatment. OBJECTIVES: A single-center, prospective, open-label study evaluating the effectiveness and safety of laser therapy for RVF treatment. SUBJECTS AND METHODS: The total of 15 patients was recruited at the Juiz de Fora University Hospital between August 2018 and July 2022. Inclusion criteria were presence of clinically suspects RVF of any etiology confirmed by pelvic magnetic resonance image (MRI) and gynecological examination. Five fractional CO2 laser sessions with monthly interval followed by complete evaluation through clinical examination and pelvic MRI were performed for all patients after the completion of treatment. Analysis of sexual function before and after the treatment was performed using Female Sexual Quotient (FSQ). RESULTS: The evaluation through physical examination showed no persistent inflammatory signs in the vagina for all patients. Additionally, 10 of out 15 (67.7%) patients achieved clinical remission of RVF symptoms, while 33.3% patients reported significant improvement. Of note, five patients who did not have previous sexual activity returned to regular sexual activity while seven patients who have baseline sexual activity had improvement in their sexual function as assessed by the FSQ. Three out of four ostomized patients had their ostomy reversed and remained without complains. All six patients with RVF secondary to Crohn's disease reported a marked improvement in symptoms and sexual function. In seven (47%) patients radiological remission was confirmed by pelvic MRI. CONCLUSION: CO2 fractional laser can be considered a promising and safe therapeutic alternative for the management of RVF.

Case Report: Treatment for Rectovaginal Fistula in Crohn's Disease Using Fractionate CO2 Vaginal Laser with Anti-TNF Therapy.

Background: Rectovaginal fistulas (RVFs) are defined as any connection between the anorectum and the vagina. They can have several causes, being Crohn's disease, the second leading cause of RVFs, responsible for ∼10% of the RVFs. Despite the advances in surgical and clinical treatment, there is no consensus regarding the best line of treatment. Objective: To report another therapeutic option, we describe the case of a patient with Crohn's disease and RVF refractory to anti-tumor necrosis factor (TNF) therapy, submitted to intravaginal CO2 fractional laser treatment. Materials and methods: Three laser sessions with monthly interval and analysis by clinical examination, sexual evaluation questionnaire, and magnetic resonance of the pelvis were performed. Results: We obtained an important improvement of the symptoms and of the dimension of the fistulous path. Conclusions: We believe this method to be a complementary, promising, and safe therapeutic alternative for the management of vaginal fistula. Future studies using this therapeutic strategy are needed to confirm the efficacy of this method in this clinical setting.

Laparoscopic treatment of rectovaginal fistulas. Feasibility, technical details, and functional results of a rare anorectal malformation.

INTRODUCTION: Rectovaginal fistulas are a rare variety of anorectal malformations. Eight patients with this anomaly among 420 children with anorectal malformations were treated in our center. We used a laparoscopic approach in 5 of the children. The aim of this study is to define the feasibility and technical details of laparoscopy in the treatment of these patients as compared with those treated by posterior sagittal anorectoplasty (PSARP) and to evaluate the preliminary results. METHODS: Three patients were treated with a PSARP starting February 2000 (group 1 [GI]). The laparoscopic approach (laparoscopic treatment [LT]) was used in the next 5 girls starting in November 2002 (group 2 [G2]). All patients were operated on by the authors. In LT cases, we used 3 ports. The rectum was dissected laparoscopically, and the fistula was transected. An assisted anorectal pull-through was then performed using a minimal perineal incision. Clinical features, age at operation, associated anomalies, ratio/sacrum (sacral ratio [SR]), distal colostogram, operative findings, complications, urinary continence, voluntary bowel movements, constipation, soiling, and requirements of bowel management program were analyzed. Patients older than 3 years and 6 months and with more than 3 months after colostomy closure were included in the analysis of functional results. RESULTS: The mean age at the time of operation was 21.8 months. Urogenital anomalies were seen in 6 (75%) of the 8 girls. Two patients had SRs less than 0.6. Only 3 patients in each group were considered for evaluation of functional results. Mean age was 67 months in 3 (G1) and 64 months in 3 (G2) patients. All 6 patients were continent of urine. Only 1 in G1 had an SR less than 0.6. Voluntary bowel movements were present in 1 patient in G1 and 2 in G2. One patient in G1 had severe constipation and grade 2 soiling requiring bowel management program (SR <0.6), and 1 patient in G2 had occasional soiling. CONCLUSIONS: Laparoscopy allowed an optimal view of the pelvis and helped to achieve a low dissection of the fistula. Although the number of patients in this study is few, functional results with LT seem to be comparable to the open PSARP approach when done by experienced pediatric surgeons. The laparoscopic approach may be considered as an option for the treatment of this rare anomaly.