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.

Colgajo de Martius como tratamiento de una fístula rectovaginal recidivada: revisión de la técnica quirúrgica a propósito de un caso clínico / Martius Flap for recurrent Rectovaginal Fístula: clinical Case and surgical approach

Resumen Introducción: La fístula rectovaginal es una patología quirúrgica compleja de tratar. El trauma perineal obstétrico y las enfermedades inflamatorias intestinales, especialmente la Enfermedad de Crohn son las causas más frecuentes. La reparación quirúrgica con un Colgajo de Martius en manos experimentadas ha mostrado buenos resultados con mínima morbilidad en pacientes seleccionados. Material y Método: Presentamos un caso clínico de una paciente que cursó con una fístula rectovaginal posparto tardía, la cual tuvo una recurrencia precoz, luego de intentar tratamiento quirúrgico consistente en un colgajo de avance, siendo necesaria la desfuncionalización del tránsito con una colostomía en asa. Posteriormente se realizó un Colgajo de Martius con resultado exitoso. Resultados: Evolución satisfactoria. Cursó con dehiscencia de la herida perineal la cual requirió solo curaciones ambulatorias. Luego de 8 meses posterior a la confección del Colgajo de Martius, se realizó el cierre de colostomía. A los 30 meses poscolgajo, la paciente se encuentra en buenas condiciones, sin evidencia de recidiva y tránsito intestinal normal. Conclusión: En este caso clínico, el colgajo de Martius fue una alternativa segura y efectiva en el tratamiento de una fístula rectovaginal recidivada.

Introduction: The rectovaginal fistula is a complex surgical pathology to treat. Obstetric perineal trauma and inflammatory bowel diseases, especially Crohn's disease, are the most frequent causes. Surgical repair with a Martius flap in experienced hands has shown good results with minimal morbidity in selected patients. Material and Methods: We present a clinical case of a patient who had a late postpartum rectovaginal fistula, which recurred early after attempting surgical treatment consisting of an advancement flap, requiring defunctionalization of the transit with a loop colostomy. Subsequently, a Martius flap was performed with a successful result. Results: Satisfactory evolution. The patient presented a dehiscence of the perineal wound which required only ambulatory dressings. At 8 months from the Martius flap was made, the colostomy was closed. At 30 months post-flap, the patient is in good condition, with no evidence of recurrence and normal intestinal transit. Conclusión: In this clinical case, the Martius flap was a safe and effective alternative in the treatment of a recurrent rectovaginal fistula.

Rectovaginal Fistula in Women With Pessary for Pelvic Organ Prolapse: A Case Series and Literature Review.

OBJECTIVE: In this study, we present a series of 2 cases of rectovaginal fistula (RVF) due to the use of a ring-type pessary in the conservative treatment of pelvic organ prolapse and a literature review on the management of RVF related to the use of pessaries. METHODS: Two patients were selected from the medical records of the urogynecology service, and their demographic and clinical data were retrieved. An updated literature review was included presenting cases of RVF induced by or after use of a pessary. RESULTS: Both patients evolved with removal of the pessary and correction of the fistula. The surgical procedures of choice were Le Fort Colpocleisis and posterior colporraphy without major complications. In the literature review, we selected 17 studies with a total of 23 cases reporting RVFs induced or followed by the use of pessaries. CONCLUSIONS: Although the pessary is commonly indicated for the conservative treatment of pelvic organ prolapse, this device is not exempt from generating complications.

Treatment of Rectovaginal Fistula Using Fractionate CO2 Vaginal Laser: A Case Series.

Background: Rectovaginal fistulas (RVFs) are abnormal tracts that connect the lower gastrointestinal tract with the vagina. They can result from obstetric trauma, infection, local surgeries, cancer, radiation damage, and Crohn's disease. Despite the advances in surgical and clinical treatment, there is no consensus regarding the best line of treatment. Objective: To report five cases of patients with RVF submitted to intravaginal CO2 fractional laser treatment, as a complementary and additional therapeutic option in this scenery. Materials and methods: Five laser sessions with monthly intervals followed by complete evaluation through clinical examination and magnetic resonance imaging of the pelvis were performed for all patients. Results: Three patients had complete resolution of symptoms after the end of planned vaginal laser sessions, whereas two patients reported significant improvement in symptoms. Four patients who had stopped having sex due to their condition admitted to resuming regular sexual activity. In addition, all five patients had closure of the fistulous track confirmed by pelvic MRI. No adverse events from vaginal laser therapy were reported by any of the patients. Conclusions: We believe this method to be a complementary, promising, and safe therapeutic alternative for the management of RVF. It may potentially enable return to regular sexual activity. Future studies using this therapeutic strategy are needed to confirm the efficacy and safety of this method in this clinical setting. Clinical trial registration no.: CAAE 93673618.4.0000.5133.

Review of Malpractice Litigations Involving Vesicovaginal and Rectovaginal Fistulas Following Elective Hysterectomy for Benign Indications in the United States From 1970 to 2020.

OBJECTIVE: The aims of this study were to review malpractice litigations involving vesicovaginal and rectovaginal fistulas after elective hysterectomy for benign indications in the United States and identify the most common themes in allegations by the plaintiffs and defenses by the defendants. METHODS: Using the Lexis Nexis legal database, we searched for and reviewed all U.S. malpractice litigations pertinent to this question between 1970 and 2020. RESULTS: Out of 82 cases that were identified and reviewed, 17 cases met our inclusion and exclusion criteria. These cases were decided between 1973 and 2019. Nine cases involved total abdominal hysterectomies, 1 involved total laparoscopic hysterectomy (TLH), 1 involved total vaginal hysterectomy (TVH), and the rest were not specified. Fifteen cases involved vesicovaginal fistulas and 2 involved rectovaginal fistulas. Three cases were ruled in favor of the plaintiffs, with monetary compensation ranging from $250,000 to $753,722 (approximately $364,120 to $1.8 million when adjusted for inflation), whereas 14 cases were ruled in favor of the defending surgeons. Common allegations were negligence in 15 cases and lack of informed consent in 2 cases. Factors that strengthened the defendants' arguments were thorough documentation, informed consent, and prompt referral to specialists. Intraoperative cystoscopy may have benefited in some cases. CONCLUSIONS: Thorough documentation, informed consent, and prompt referral to specialists strengthened the defendants' legal arguments. Intraoperative cystoscopy may also be beneficial.

Tratamento tardio de atresia anal associado ao megacólon e fístula reto-vaginal em um canino de três meses: relato de caso / Late treatment of atresia anal associated to megacolon and rectrovaginal fistula in a 3 month canine: case report / Tratamiento tardio de la atresia anal associada com megacólon y fistula retovaginal em um canino de 3 meses: reporte de caso

Atresia Anal (AA) é caracterizada por uma afecção congênita/hereditária, na qual a abertura do ânus está ausente ou obstruída e, muitas vezes pode levar a graves complicações como: fístula reto-vaginal, eritema perivulvar, diarreia e o megacólon que, influenciam diretamente no prognóstico e tratamento do animal. Nesse trabalho, objetivou-se o relato de uma cadela com AA não corrigida, da raça Boston Terrier, com três meses de idade, atendida no HEV-UNIFAJ, relatando conteúdo fecal sendo excretado pela vulva. Observou-se orifício anal imperfurado e presença de fístula reto-vaginal sendo realizado anoplastia/vulvoplastia como tratamento. Salienta-se a importância de tratamento cirúrgico precoce para um prognóstico satisfatório.

Anal atresia (AA) is characterized by a congenital/hereditary condition, which the opening of the anus is absent or obstructed and can often lead to serious complications such as recto-vaginal fistula, perivulvarerythema, diarrhea and megacolon that influence directly in the prognosis and treatment of the animal. The objective of this study was to report a three-month-old Boston Terrier bitch with uncorrected AA atlended at HEV-UNIFAJ, reporting fecal content being excreted by the vulva. Were observed imperforated anal orifice and presence of rectovaginal fistula and was performed anoplasty/vulvoplasty as treatment. The importance of early surgical treatment for a satisfactory prognosis is emphasized.

La atresia anal (AA) se caracteriza por una afección congénita/hereditaria en que la abertura del ano está ausente u obstruida y a menudo puede provocar complicaciones graves como fístula recto-vaginal, eritema perivulvar, diarrea y megacolon que influyen directamente en el pronóstico y tratamiento dei animal. El objetivo de este estudio fue informar sobre una perra de Boston Terrier de tres meses con AA no corregida tratada en HEV-UNIFAJ, informando que el contenido fecal es excretado por la vulva. Se observaron orificios anales imperforados y presencia de fístula rectovaginal y se realizó anoplastia/vulvoplastia como tratamiento. Se enfatiza la importancia del tratamiento quirúrgico temprano para un pronóstico satisfactorio.

Tratamento tardio de atresia anal associado ao megacólon e fístula reto-vaginal em um canino de três meses: relato de caso / Late treatment of atresia anal associated to megacolon and rectrovaginal fistula in a 3 month canine: case report / Tratamiento tardio de la atresia anal associada com megacólon y fistula retovaginal em um canino de 3 meses: reporte de caso

Atresia Anal (AA) é caracterizada por uma afecção congênita/hereditária, na qual a abertura do ânus está ausente ou obstruída e, muitas vezes pode levar a graves complicações como: fístula reto-vaginal, eritema perivulvar, diarreia e o megacólon que, influenciam diretamente no prognóstico e tratamento do animal. Nesse trabalho, objetivou-se o relato de uma cadela com AA não corrigida, da raça Boston Terrier, com três meses de idade, atendida no HEV-UNIFAJ, relatando conteúdo fecal sendo excretado pela vulva. Observou-se orifício anal imperfurado e presença de fístula reto-vaginal sendo realizado anoplastia/vulvoplastia como tratamento. Salienta-se a importância de tratamento cirúrgico precoce para um prognóstico satisfatório.(AU)

Anal atresia (AA) is characterized by a congenital/hereditary condition, which the opening of the anus is absent or obstructed and can often lead to serious complications such as recto-vaginal fistula, perivulvarerythema, diarrhea and megacolon that influence directly in the prognosis and treatment of the animal. The objective of this study was to report a three-month-old Boston Terrier bitch with uncorrected AA atlended at HEV-UNIFAJ, reporting fecal content being excreted by the vulva. Were observed imperforated anal orifice and presence of rectovaginal fistula and was performed anoplasty/vulvoplasty as treatment. The importance of early surgical treatment for a satisfactory prognosis is emphasized.(AU)

La atresia anal (AA) se caracteriza por una afección congénita/hereditaria en que la abertura del ano está ausente u obstruida y a menudo puede provocar complicaciones graves como fístula recto-vaginal, eritema perivulvar, diarrea y megacolon que influyen directamente en el pronóstico y tratamiento dei animal. El objetivo de este estudio fue informar sobre una perra de Boston Terrier de tres meses con AA no corregida tratada en HEV-UNIFAJ, informando que el contenido fecal es excretado por la vulva. Se observaron orificios anales imperforados y presencia de fístula rectovaginal y se realizó anoplastia/vulvoplastia como tratamiento. Se enfatiza la importancia del tratamiento quirúrgico temprano para un pronóstico satisfactorio.(AU)

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.

Síndrome de Mayer-Rokitansky- Küster-Hauser asociado con malformación anorectal / Mayer-Rokitansky-Küster-Hauser syndrome associated with anorectal malformation

La agenesia vaginal es una entidad poco frecuente que puede presentarse en forma aislada o acompañada de otras anomalías congénitas. El desconocimiento de esta asociación puede retardar su diagnóstico, causar complicaciones indeseadas y comprometer el resultado del tratamiento. Se describen tres casos clínicos con agenesia vaginal y malformación anorrectal, cuyos diagnósticos no fueron realizados en el momento del nacimiento. Aunque la coexistencia de anomalías vaginales y anorectales sean poco frecuentes, los médicos responsables de su tratamiento deben ser conscientes de su existencia y practicar examen perineal cuidadoso.

Vaginal agenesis is a rare condition. It may exist in isolation or be associated with other congenital anomalies. A lack of awareness on this association may delay diagnosis, cause undesirable complications and compromise treatment outcomes. We describe three cases of vaginal agenesis associated with anorectal malformation which were not diagnosed at birth. Although the coexistence of vaginal and anorectal anomalies is uncommon, treating physicians should be aware of them and perform a detailed perineal examination.

[Martius procedure in complex anorectal-vaginal fistula management: five-case report]. / Manejo de la fístula ano-recto-vaginal compleja mediante el procedimiento de Martius: reporte de cinco casos.

The repair of complex anorectal-vaginal fistulas represents an anatomic-surgical challenge for the surgeon, and the appropriate surgical procedure must be selected for each case. The procedure of Martius is described as the transposition of the bulbocavernosus muscle to repair the recto-vaginal fistula. Five cases of anorectal-vaginal fistulae were repaired by this procedure from 2010 to 2014. The mean age was 38.2 years; three fistulas (60%) were of obstetric etiology, one induced by radiation and one of unknown etiology. The mean follow-up was 25 months, with a 100% success rate. The Martius procedure is a good alternative for the surgical repair of complex anorectal-vaginal fistulas.

Manejo de la fístula ano-recto-vaginal compleja mediante el procedimiento de Martius: reporte de cinco casos / Martius procedure in complex anorectal-vaginal fistula management: five-case report

La reparación de fístulas ano-recto-vaginales complejas representa un reto anatomoquirúrgico para el cirujano, debiendo seleccionarse el procedimiento quirúrgico adecuado para cada caso. El procedimiento de Martius consiste en la trasposición del músculo bulbocavernoso para reparar la fístula recto-vaginal. Se presentan cinco casos de fístulas ano-recto-vaginales reparadas por este procedimiento desde el 2010 hasta el 2014. La edad promedio fue de 38,2 años, tres fístulas (60%) fueron de etiología obstétrica, una inducida por radiación y otra de etiología desconocida. El seguimiento promedio fue de 25 meses, con una tasa de éxito de 100%. El procedimiento de Martius es una buena alternativa para la reparación quirúrgica de fístulas ano-recto-vaginales complejas.

The repair of complex anorectal-vaginal fistulas represents an anatomic-surgical challenge for the surgeon, and the appropriate surgical procedure must be selected for each case. The procedure of Martius is described as the transposition of the bulbocavernosus muscle to repair the recto-vaginal fistula. Five cases of anorectal-vaginal fistulae were repaired by this procedure from 2010 to 2014. The mean age was 38.2 years; three fistulas (60%) were of obstetric etiology, one induced by radiation and one of unknown etiology. The mean follow-up was 25 months, with a 100% success rate. The Martius procedure is a good alternative for the surgical repair of complex anorectal-vaginal fistulas.

Atresia anal com fístula retovaginal em ovino: relato de caso / Anal Atresia with rectovaginal fistula in sheep: case report

A atresia anal com fístula retovaginal, é considerada uma afecção congênita rara nos ovinos. Em virtude disso, buscou-se descrever o reparo cirúrgico e cuidados pós-operatórios em uma borrega que apresentava essa afecção. Nesse sentido, uma borrega, sem raça definida, de 25 dias de idade e pesando 7,2kg, apresentou sinais de distensão abdominal e defecação pela vulva. A afecção foi diagnosticada por meio do exame clínico e confirmada radiograficamente, constatando-se atresia anal do tipo III em associação com a fístula.(AU)

Atresia ani associated with rectovaginal fistula is considered a rare congenital anomaly in sheep. Therefore, the surgical correction and post-operative care of a lamb presenting atresia ani with rectovaginal fistula has been detailed in this case report. A 25-days old, mixed breed lamb, weighing 7.2 kg, showing signs of abdominal bloating, and stool passage through the vulva was admitted at our hospital. An atresia ani type III condition associated with rectovaginal fistula was diagnosed by clinical examination and confirmed by radiographic examination.(AU)

Atresia anal com fístula retovaginal em ovino: relato de caso / Anal Atresia with rectovaginal fistula in sheep: case report

A atresia anal com fístula retovaginal, é considerada uma afecção congênita rara nos ovinos. Em virtude disso, buscou-se descrever o reparo cirúrgico e cuidados pós-operatórios em uma borrega que apresentava essa afecção. Nesse sentido, uma borrega, sem raça definida, de 25 dias de idade e pesando 7,2kg, apresentou sinais de distensão abdominal e defecação pela vulva. A afecção foi diagnosticada por meio do exame clínico e confirmada radiograficamente, constatando-se atresia anal do tipo III em associação com a fístula.(AU)

Atresia ani associated with rectovaginal fistula is considered a rare congenital anomaly in sheep. Therefore, the surgical correction and post-operative care of a lamb presenting atresia ani with rectovaginal fistula has been detailed in this case report. A 25-days old, mixed breed lamb, weighing 7.2 kg, showing signs of abdominal bloating, and stool passage through the vulva was admitted at our hospital. An atresia ani type III condition associated with rectovaginal fistula was diagnosed by clinical examination and confirmed by radiographic examination.(AU)

Alternativas quirúrgicas en el manejo de la fístula rectovaginal: experiencia de 25 años / Surgical procedures for rectovaginal fistula: 25-years experience

Antecedentes: La fístula rectovaginal (FRV) es una patología de origen muy variado y el tratamiento representa un verdadero desafío terapéutico. No existen estudios prospectivos que orienten sobre el manejo de estas lesiones. Objetivo: Evaluar los resultados del tratamiento quirúrgico de las pacientes con una FRV. Material y método: Estudio descriptivo retrospectivo en el cual se incluyen todas las pacientes intervenidas en un periodo de 25 años. Resultados: Se trata de 63 pacientes con una FRV, la mitad secundaria a una neoplasia y un 27% secundaria al tratamiento radiante de tumores pélvicos. El trauma local y las FRV postoperatorias representan el 28% de los casos. El abordaje de la FRV fue abdominal en 26 pacientes (41%), resecando la FRV neoplásica en 11 y efectuando una cirugía reconstructiva en 15 actínicas. En 17 pacientes con una FRV por persistencia tumoral solo se efectuó una desfuncionalización proximal. De las 5 pacientes con una FRV iatrogénica, en 4 se logró el cierre espontáneo mediante una ostomía transitoria y los 7 casos de FRV posparto fueron reparadas con un abordaje local con resultados satisfactorios en 6. Conclusiones: En este estudio el abordaje local de la FRV se utilizó en 12 casos; el 33% (21/63) de los casos necesitó una ostomía definitiva y en el 40% de las fístulas complejas se logró el cierre de la fístula con conservación esfinteriana. Las series de FRV publicadas son muy heterogéneas, probablemente debido a patrones de referencia muy variables, lo que hace muy difícil realizar un análisis comparativo.

Background: Rectovaginal fistula (RVF) is a distressing condition with no generally accepted standard surgical management. Aim: To assess results of surgery for RVF. Material and method: This is a descriptive retrospective analysis of 63 patients operated on consecutively for RVF in a period of 25 years. Results: Halve of the cases were secondary to a pelvic malignancy and 27% due to radiotherapy of pelvic tumors. RVFs were associated with local (obstetrical) trauma and postsurgical complications in 28% of the cases. High RVFs were approached through abdominal procedures in 26 patients (41%), including radical resection of the primary tumor in 11 cases and coloanal sleeve anastomosis procedure in 15 patients with a RVF due to pelvic radiation. Seventeen patients with persistent pelvic tumors after radiotherapy and/or surgery were handled with a colostomy or ileostomy to improve quality of life. Four of five cases with postsurgical RVF closed spontaneously with a proximal colostomy and, in seven patients with obstetrical RVF, an advancement flaps were performed, with success in 6. Conclusions: In this study local repair of RVF was employed in 12 cases, one third of the cases needed a permanent ostomy, and 40% of the complex cases of RVF were successfully repaired with sphincter preservation. Comparisons with other studies are precluded because of heterogeneity of published RVF series, probably due to different patterns of reference.