Use of a unilateral pudendal thigh flap in the treatment of complex rectovaginal fistula

Modified Internal Pudendal Artery Perforator Flap Interposition for Rectovaginal Fistula

IMPORTANCE

Rectovaginal fistula (RVF) is a challenging condition associated with recurrences and significant functional impairment.

OBJECTIVES

The internal pudendal artery perforator (IPAP) flap has become a viable option for reconstructing the vagina and perineal regions. This study aims to introduce a modified technique of IPAP flap interposition and evaluate its postoperative outcomes in the treatment of low RVF.

STUDY DESIGN

Sixteen patients with RVF who underwent modified IPAP flap interposition between 2016 and 2021 were retrospectively enrolled. Recurrence rate, the satisfaction of vulvar appearance (Visual Analog Scale), and quality of sexual life (Female Sexual Function Index score) were followed up and analyzed.

RESULTS

All patients presented with low fistula with a mean diameter of 8.3 mm. The mean width and length of the IPAP flaps were 3.8 and 6.2 cm, respectively. The mean follow-up period was 14.1 months. All patients achieved successful healing without recurrence. High satisfaction was reported for the cosmetic effect of the vulva with a mean Visual Analog Scale score of 8.4. The proportion of female sexual disorder exhibited a statistically significant reduction, decreasing from 100% preoperatively to 38% after surgery (P < 0.05).

CONCLUSIONS

The modified IPAP flap interposition is a reliable and safe option for repairing low RVF, with high success rates and minimal donor site morbidity. Moreover, this procedure provides a suitable volume flap and preserves the vaginal physiological environment, which benefits postoperative sexual function.

Traumatic deficient perineum: surgical management and outcome from a single center

INTRODUCTION AND HYPOTHESIS

Deficient perineum is a disruption of the perineal body and distal rectovaginal septum presenting with anal incontinence and a range of urogenital symptoms. There is scarce reported outcome of this condition with management often delayed and with a variety of surgical alternatives. This study aims to determine faecal continence outcomes after long-term surgical repair.

METHODS

Patients were included for analysis after surgical repair between 1989 and 2012. Cases were preoperatively assessed by endosonography and anorectal manometry with a record of their continence with the Cleveland Clinic Incontinence Score (CCIS). Surgical repair comprised an overlapping repair of the external anal sphincter (EAS) with levatorplasty. There was selective use of internal anal sphincter (IAS) suture and/or advancement perineoplasty for soft tissue reconstruction. Patients were clinically evaluated for functional outcomes with comparison of their postoperative CCIS.

RESULTS

There were 20 patients (median age 55.5 years; range 29-81 years) with a median duration of incontinence symptoms of 174 (range 1-540) months. All patients had an EAS and IAS defect with 14 (70%) undergoing an IAS suture and 10 (50%) a Corman-style anoplasty. Over a median follow-up of 137.2 (range 13-322) months, there was a significant decrease in the recorded median preoperative vs. postoperative CCIS 18, range 13-20 vs. 2, range 0-10, respectively; p < 0.001) with 18 (90%) satisfied with the functional outcome. Faecal diversion was not used in any of the patients.

CONCLUSIONS

Experienced delayed repair of a traumatic cloaca is associated with an acceptable functional outcome at medium- to long-term follow-up.

Long-term success of complex recurrent rectovaginal fistula repair

Rectovaginal fistulas (RVF) are the cause of major affliction to the affected patient and are a foremost challenge for the attending surgeon. Traditional techniques for treatment of RVF are quite extensive and particularly invasive. A more local procedure, with an acceptable success rate, would be the ideal first approach in treatment of this particular ailment. The aim of the current study is to show the step-by-step technique to correct a complex recurrent RVF (rRVF) using a biomesh implant. A 61-year-old female, who had undergone a prior vaginal hysterectomy, presented with a complex recurrent RVF. A third attempt to repair the RVF was conducted by a surgical team with the utilization of a biomesh, which resulted in no further recurrence of symptoms or RVF for up to 4 years. Complex rRVF repair by the placement of the biomesh allows for a secure and sustainable closure with potentially better prognosis for the patients.

Coverage of the scrotum after Fournier's gangrene

Background: Fournier’s gangrene is a necrotizing fasciitis caused by mixed aerobic and anaerobic bacteria and results in loss of skin and subcutaneous tissue in the perineal area. Coverage of testis varies from closure of the defect primarily, burying inside the thigh, using the remnants of the scrotum for tissue expansion and coverage by flaps. In this manuscript, scrotal advancement flaps and pudendal thigh flaps were used for coverage of the testis unilaterally or bilaterally according to the size of the defect following Fournier gangrene.

Patients and methods: From June 2015 to March 2017, twelve cases were admitted to our department. The patients’ ages ranged from 37–59 years and they all had suffered from Fournier’s gangrene in the perineal area.

Results: Of the twelve cases, two cases showed penile involvement. A skin graft was used for coverage of the penile shaft with excellent take. Four cases were closed primarily. This was applied to cases where loss of skin was less than 50%. The rest of the cases were reconstructed by pudendal thigh flap. The reconstructed cases were covered by bilateral pudendal thigh flap (4 cases) and unilateral pudendal thigh flap (4 cases). The follow-up extended up to 16 months.

Conclusion: Scrotal advancement flap was suitable for small and medium size defects due to the elasticity of the scrotal skin. Pudendal thigh flap was efficient for the reconstruction of large defects of the scrotum.

The disappointing quality of published studies on operative techniques for rectovaginal fistulas: a blueprint for a prospective multi-institutional study

BACKGROUND

Treatment of rectovaginal fistulas is difficult, and many surgical interventions have been developed. The best surgical intervention for the closure of these fistulas is still unclear.

OBJECTIVE

A systematic review was performed reporting the outcomes of different surgical techniques for rectovaginal fistulas.

DATA SOURCES

Medline (PubMed, Ovid), Embase (Ovid), and The Cochrane Library databases were searched for eligible articles as well as the references of these articles.

STUDY SELECTION

Two independent reviewers analyzed the search results for eligible articles based on title, abstract, and described results.

INTERVENTION(S)

Any surgical intervention for the closure of rectovaginal fistulas was included.

MAIN OUTCOME MEASURES

The main outcome was closure rate. Secondary outcomes were quality of life, morbidity, and the effect on sexual functioning.

RESULTS

Many articles with different operative techniques were identified and classified in the following categories: advancement flaps (endorectal and endovaginal), transperineal closure, Martius procedure, gracilis muscle transposition, rectal resections, transabdominal closure, mesh repair, plugs, endoscopic repairs, closure with biomaterials, and miscellaneous techniques. Results vary widely with closure rates between 0% and >80%. None of the studies were randomized. Because of the poor quality of the identified studies, the comparison of results and performance of a meta-analysis were not possible.Data regarding the secondary outcomes were mostly unavailable.

LIMITATIONS

The major limitation of this review was the limited availability of high-quality prospective studies, making it impossible to perform a meta-analysis.

CONCLUSIONS

No conclusion about the best surgical intervention for rectovaginal fistulas could be formulated. More large studies of high quality are needed to find the best treatment for rectovaginal fistulas. A design for these high-quality studies was formulated.

Rectovaginal fistula: a new technique and preliminary results using collagen matrix biomesh

BACKGROUND

A rectovaginal fistula (RVF) is a debilitating condition that is difficult to treat. Many available techniques are invasive and involve extensive surgery. A local procedure with good closure rates would be preferable as a first step in the treatment of RVF. The aim of this study was the development of a local technique for the closure of RVF with good closure rates to prevent the use of more invasive procedures.

METHODS

This was a pilot study. Patients with RVF who had undergone multiple operations in the pelvic area, local radiotherapy, chemotherapy or had been diagnosed with Crohn's disease were included in the study. All had a history of surgery for RVF. A cross-linked collagen matrix biomesh was placed in the rectovaginal septum using a transperineal or a transvaginal approach. The main outcome measure in this study was the closure rate reported as absence of the fistula at 1 year.

RESULTS

Twelve patients were included in the study. Absence of fistula at 1 year was 0.64 (95 % confidence interval 0.30-0.85). Three patients (25.0 %) developed a recurrence, two were reoperated on with a gracilis flap transposition, and one was treated with laparoscopic ligation. In one patient (8.3 %), the fistula failed to close within 3 months after the mesh placement.

CONCLUSIONS

Our technique shows promising results. A local and simple technique with acceptable closure and morbidity rates, like our local repair with biomesh, would be ideal as a first step in treating RVFs. Long-term results are needed.

Minimally invasive treatment of rectovaginal fistula

BACKGROUND

Rectovaginal fistulas (RVFs) are a rare surgical condition. Their treatment is extremely difficult, and no standard surgical technique is accepted worldwide. This report describes a new approach using transanal endoscopic microsurgery (TEM) to treat RVFs.

METHODS

A retrospective review of 13 patients who underwent repair of rectovaginal fistula using TEM between 2001 and 2008 was undertaken. The surgical technique is widely described, and the advantages of the endorectal approach are noted.

RESULTS

The median follow-up period was 25 months, and the median age of the patients was 44 years (range, 25-70 years). The mean operative time was 130 min (range, 90-150 min), and the hospital stay was 5 days (range, 3-8 days). One patient experienced recurrence. This patient underwent reoperation with TEM and experienced re-recurrence. Two patients had minor complications (hematoma of the septum and abscess of the septum), which were treated with medical therapy. For two patients, a moderate sphincter hypotonia was registered.

CONCLUSIONS

A new technique for treating RVFs using TEM is presented. The authors strongly recommend this approach that avoids any incision of the perineal area, which is very painful and can damage sphincter functions.

The pudendal thigh flap for vaginal reconstruction: optimising flap survival

BACKGROUND

The pudendal thigh fasciocutaneous (PTF) flap is a useful flap in perineal reconstruction, that is reliable when small but is traditionally unreliable when large flaps are raised. Large flaps in particular, are associated with an increased incidence of apical necrosis. Thorough descriptions of the vascular anatomy of this flap have been lacking from the literature, with the current study evaluating this anatomy, aiming to provide the anatomical basis for vascular problems and for techniques to maximise its survival.

METHODS

Five unembalmed human cadaveric pelvis specimens were studied. Lead oxide injectant enabled radiographic and dissection analysis of the arterial anatomy of the integument of the perineum.

RESULTS

A consistent pattern of vascular supply was found in all specimens. 1: the blood supply to the pelvic floor was supplied sequentially by the posterior labial/scrotal arteries, cutaneous branches from the anterior branch of the obturator artery, and branches from the external pudendal arteries. 2: these vessels ran close to the midline, medial to the PTF flap. 3: the posterior labial/scrotal arteries were deep to the Colles' fascia and the branches from the obturator artery and external pudendal arteries were located superficial to the Colles' fascia.

CONCLUSION

This study has demonstrated that the PTF flap is a three vascular territory flap and that the pedicle is situated close to the midline. This may explain why regions of the PTF flap may have a potentially precarious blood supply, and suggests that the PTF flap should be designed more medially. Given the third territory of supply to the apex of the flap, a delay procedure may help to avoid flap necrosis.

Rectovaginal radiation fistula repair using an obturator fasciocutaneous thigh flap

BACKGROUND

Rectovaginal fistulae are a known complication of pelvic radiotherapy utilizing locally applied isotope implants. Most often, either permanent colostomy or reconstruction with a well-vascularized flap is necessary. Traditional techniques for fistula repair utilize bulky muscle flaps, disfiguring pudendal artery flaps or may require laparotomy.

CASE

We describe the management of a 26-year-old woman with a large radiation-induced rectovaginal fistula. A fasciocutaneous medial thigh flap based on terminal branches of the obturator artery and vein was used without colostomy and resulted in pain-free sexual function and minimal vulva disfigurement.

CONCLUSION

A medial thigh fasciocutaneous flap without muscle can be transferred into the vagina on the obturator vessels and may become the preferred method for managing large rectovaginal fistulas.

The versatility of the pudendal thigh fasciocutaneous flap used as an island flap

The pudendal thigh flap is a sensate fasciocutaneous flap based on the terminal branches of the superficial perineal artery, which is a continuation of the internal pudendal artery. Several authors have reported using this axial patterned flap in a bilateral fashion to reconstruct the vagina, mostly in patients with vaginal atresia. The technique is simple, safe, and reliable, and no stents or dilators are required. The reconstructed vagina has a natural angle and is sensate. The donor site in the groin can be closed primarily with an inconspicuous scar. The distinct advantages of this flap widen its indications to several other pathologies. In this article, the authors report on the bilateral use of the flap to reconstruct a vagina in patients with congenital atresia (n = 8) and after oncological resection (n = 5). Furthermore, the versatility of this island flap is also demonstrated by its use in a unilateral fashion in patients with recurrent or complex rectovaginal fistulas (n = 4) and in two patients with a defect of the posterior urethra in a heavily scarred perineum. All 31 pudendal thigh flaps survived completely. Some wound dehiscence was observed in two patients. Two other patients required a minor correction at the introitus of the vagina. The functional outcome was excellent in all patients, despite the presence of some hair growth in the flaps. This article discusses the expanding indications of this versatile flap and the refinements in operative technique.