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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.

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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.

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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.

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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.

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Abstract Introduction: There is a high rate of deliveries in adolescents in Mexico. This age group is vulnerable to obstetric complications, including lacerations of the anal sphincter. Objective: To determine the prevalence of third and fourth degree perineal tears in adolescents during childbirth, and to evaluate risk factors in comparison with deliveries with lacerations of adult women. Methods: All obstetric care episodes were reviewed from a public tertiary hospital data in Monterrey, Mexico in 2014. Age, primiparity, delivery instrumentation, episiotomy, body mass index, product weight and tear´s degree were documented at the deliveries with tears of third and fourth degree. Results: The prevalence of third and fourth degree tears of 2.0% was found in the general population, being adolescents the most affected with 2.5%. The unadjusted odds ratio of high-grade tears in adolescent females at delivery, compared to adult females, was 1.36 (95% CI = 0.99-1.86, p= 0.05). No difference was found when comparing risk factors among high-grade tear deliveries in adolescents versus adults. Conclusions: A higher prevalence than previous reported for high grade tears during delivery was found. The data suggest adolescence as a risk factor for high-grade tears during delivery.

Resumen Introducción: En México hay una elevada tasa de partos en adolescentes. Este grupo es vulnerable para complicaciones obstétricas, entre ellas laceración del esfínter anal. Objetivo: Conocer la prevalencia de desgarros perineales de tercer y cuarto grado en adolescentes durante el parto y evaluar factores de riesgo en comparación con partos con laceración de mujeres adultas. Métodos: Se revisaron todas las atenciones obstétricas en un hospital publico de tercer nivel en Monterrey, Nuevo León, México en el año 2014. Se documentó edad, primiparidad, instrumentación del parto, realización de episiotomía, índice de masa corporal, peso del producto y grado del desgarro en los partos que presentaron desgarros de tercer y cuarto grado Resultados: Se encontró una prevalencia general de 2.0% de desgarros de tercer y cuarto grado y en adolescentes de 2.5%. La razón de momios sin ajustar de desgarros de alto grado en mujeres adolescentes en comparación con mujeres adultas fue de 1.36 (IC 95%= 0.99-1.86, p= 0.05). No se encontró diferencia al comparar factores de riesgo entre los partos con desgarro de alto grado en adolescentes contra adultas. Conclusiones: Se encontró una prevalencia mayor a lo reportado de desgarros de alto grado durante el parto. Los datos sugieren a la adolescencia como factor de riesgo para desgarros de alto grado.

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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.

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INTRODUCTION: There is a high rate of deliveries in adolescents in Mexico. This age group is vulnerable to obstetric complications, including lacerations of the anal sphincter. OBJECTIVE: To determine the prevalence of third and fourth degree perineal tears in adolescents during childbirth, and to evaluate risk factors in comparison with deliveries with lacerations of adult women. METHODS: All obstetric care episodes were reviewed from a public tertiary hospital data in Monterrey, Mexico in 2014. Age, primiparity, delivery instrumentation, episiotomy, body mass index, product weight and tear´s degree were documented at the deliveries with tears of third and fourth degree. RESULTS: The prevalence of third and fourth degree tears of 2.0% was found in the general population, being adolescents the most affected with 2.5%. The unadjusted odds ratio of high-grade tears in adolescent females at delivery, compared to adult females, was 1.36 (95% CI = 0.99-1.86, p= 0.05). No difference was found when comparing risk factors among high-grade tear deliveries in adolescents versus adults. CONCLUSIONS: A higher prevalence than previous reported for high grade tears during delivery was found. The data suggest adolescence as a risk factor for high-grade tears during delivery.

INTRODUCCIÓN: En México hay una elevada tasa de partos en adolescentes. Este grupo es vulnerable para complicaciones obstétricas, entre ellas laceración del esfínter anal. OBJETIVO: Conocer la prevalencia de desgarros perineales de tercer y cuarto grado en adolescentes durante el parto y evaluar factores de riesgo en comparación con partos con laceración de mujeres adultas. MÉTODOS: Se revisaron todas las atenciones obstétricas en un hospital publico de tercer nivel en Monterrey, Nuevo León, México en el año 2014. Se documentó edad, primiparidad, instrumentación del parto, realización de episiotomía, índice de masa corporal, peso del producto y grado del desgarro en los partos que presentaron desgarros de tercer y cuarto grado. RESULTADOS: Se encontró una prevalencia general de 2.0% de desgarros de tercer y cuarto grado y en adolescentes de 2.5%. La razón de momios sin ajustar de desgarros de alto grado en mujeres adolescentes en comparación con mujeres adultas fue de 1.36 (IC 95%= 0.99-1.86, p= 0.05). No se encontró diferencia al comparar factores de riesgo entre los partos con desgarro de alto grado en adolescentes contra adultas. CONCLUSIONES: Se encontró una prevalencia mayor a lo reportado de desgarros de alto grado durante el parto. Los datos sugieren a la adolescencia como factor de riesgo para desgarros de alto grado.

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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.

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Objetivo: Presentar un tratamiento alternativo para una fistula recto vaginal grande producida por la radiación en una mujer joven tratada por cáncer de cuello uterino, basado en las sigmoideoplastias vaginales en pacientes con agenesia de vagina. Paciente y método: Paciente de sexo Femenino de 36 años que el año 2010 concurre al consultorio de proctología por presentar proctorragia asociada a la defecación de dos semanas de evolución. Antecedentes de conización en el año 2008 por carcinoma epidermoide de cuello uterino y en 2009 irradiada con braquiterapia y radioterapia por presentar recidiva en vagina de cáncer de cuello uterino. Se decide la internación y al día siguiente es llevada a quirófano donde se observa a nivel de recto inferior y medio, fístula con tercio medio e inferior de vagina de unos 4 a 5 cm de diámetro. Dada las características de la misma, el grado de incontinencia de la paciente, su retracción inmediata de sus actividades laborales y sociales, se le plantea la posibilidad de desfuncionalizarla resecado el recto medio e inferior, completar la cirugía oncológica de su cáncer y en un segundo acto reconstruir tanto el tránsito intestinal como su vagina con un segmento vascularizado de colon. Discusión: Existen varias formas de clasificar una fistula rectovaginal, en base a su ubicación, según su diámetro, por último se pueden clasificar según su complejidad en simples y complejas. Dentro de los tratamientos hallamos los perineales, rectales o vaginales, indicados en las fistulas bajas o medias y los abdominales en las fistulas altas. Existen algunas que no responde a los tratamientos habituales o que desde un principio no se pueden tratar por las técnicas habituales, llevando en contadas ocasiones a tratamientos más agresivos como la desfuncionalización, colgajos miocutáneos o la técnica de Simonsen.

Purpose: to present an alternative treatment for rectovaginal fistula secondary to radiation in a young female patient treated for cervical cancer, based on a vaginal sigmoideoplasty. Patient and Method: 36 years old female patient with a 2-week history of rectal bleeding. Personal history of conization in 2008 for cervical squamous carcinoma and postoperative treatment in 2009 with brachytherapy and radiaton therapy for local cancer recurrence. On surgical perineal exploration a recto-vaginal defect of 4-5 cm was identified in the middle-lower vagina. Proctectomy was performed based in surgical principles. During reconstructive surgery the vagina was replaced with a colonic segment. Results: there are several ways to classify a rectovaginal fistula, based on location, diameter and according to their complexity into simple and complex. Rectal, perineal and vaginal approaches have been described. In some cases, more aggressive techniques could be performed such as myocutaneous flaps and Simonsen technique.

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Introducción: Las fístulas rectovaginales ocurren con una frecuencia menor a 5 % respecto a otros tipos de fístulas de la región anorrectal; el trauma obstétrico es la causa más común de este tipo de fístulas. Existen diversos procedimientos quirúrgicos para la reparación de las mismas. Material y métodos: Se realizó un estudio de 16 pacientes con diagnóstico de fístula rectovaginal posobtétrica, atendidas en el Hospital Juárez de México entre enero de 1992 y diciembre de 2006. Se analizó edad de las pacientes, tipo de trauma obstétrico, tiempo de inicio de la sintomatología después del parto, localización y tamaño de la fístula, índice de éxito y recidivas mediante el tratamiento con avance de colgajo endorrectal, y necesidad de esfinteroplastia complementaria. Resultados: La edad promedio fue de 25.6 años. En todas las pacientes, la sintomatología inició después de un parto vaginal durante el cual se realizó episiotomía o hubo desgarro perineal. Todas las fístulas fueron menores de 2.5 cm de diámetro y de localización baja. Con el colon preparado, en todas las pacientes se reparó la fístula rectovaginal mediante avance de colgajo endorrectal. En dos pacientes se llevó acabo, además, esfinteroplastia del esfínter anal. Los resultados fueron satisfactorios en 15 pacientes (93.7 %); no hubo mortalidad operatoria y no fueron utilizados estomas de protección. Conclusiones: El colgajo endorrectal es un procedimiento seguro para la reparación de fístulas rectovaginales de origen posobstétrico, algunos casos pueden requerir esfinteroplastia del esfínter anal.

BACKGROUND: Rectovaginal fistulas account for <5% of all rectal fistulas. Obstetrical injuries are the most common cause of these types of fistulas. There have been a multitude of surgical approaches developed for operative repair. METHODS: Between January 1992 and December 2006, 16 patients with postobstetric rectovaginal fistula were treated at the Hospital Juárez of México. Age, type of obstetric trauma, time elapsed between delivery and beginning of symptoms, location, and size of the fistulas, rate of success and recurrence with the use of endorectal flap, and need for complementary sphincteroplasty were all evaluated. RESULTS: Median age of the patients was 25.6 years. All women reported that their symptoms began after a vaginal delivery that included an episiotomy or 4th degree laceration. All fistulas were low and small (<2.5 cm in diameter). Patients received bowel preparation and underwent rectovaginal repair using endorectal advancement flap. In two cases, additional overlap repair of the anal sphincter was performed. Result of repair was good to excellent in 15 patients (93.7%). There were no operative mortalities, and no covering stomas were used. CONCLUSIONS: Endorectal flap repair provides successful postobstetric rectovaginal fistula closure. Concomitant sphincteroplasty may be necessary in some cases.

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