Interposition of a biological mesh may not affect the rate of rectovaginal fistula after excision of large rectovaginal endometriotic nodules: a pilot study of 209 patients

Abstract

Aim The aim of this work was to assess whether placement of a biological mesh (Permacol®) between the vaginal and rectal sutures reduces the rate of rectovaginal fistula in patients with deep rectovaginal endometriosis. Method We report a retrospective, comparative study enrolling patients with vaginal infiltration of more than 3 cm in diameter and rectal involvement in two centres. They benefited from complete excision of rectovaginal endometriotic nodules with or without a biological mesh placed between the vaginal and rectal sutures. The rate of rectovaginal fistula was compared between the two groups. Results Two hundred and nine patients were enrolled: 42 patients underwent interposition of biological mesh (cases) and 167 did not (controls). Ninety‐two per cent of cases and 86.2% of controls had rectal infiltration more than 3 cm in diameter. Cases underwent rectal disc excision more frequently (64.3% vs. 49.1%) and had a smaller distance between the rectal staple line and the anal verge (4.4 ± 1.4 cm vs. 6 ± 2.9 cm). Rectovaginal fistulas occurred in 4 cases (9.5%) and 12 controls (7.2%). Logistic regression analyses revealed no difference in the rate of rectovaginal fistula following the use of mesh (adjusted OR 1.6, 95% CI 0.3–9.5). A distance of less than 7 cm between the rectal staple line and the anal verge was found to be an independent risk factor for the development of rectovaginal fistula (adjusted OR 15.1, 95% CI 1.7–132). Conclusion Our results suggest that the placement of a biological mesh between the vagina and rectal sutures may not affect the rate of formation of postoperative rectovaginal fistula following excision of deep infiltrating rectovaginal endometriosis.

Combined vaginal natural orifice transluminal endoscopic surgery and robotic excision of large endometriosis nodule of low rectum, vagina and both parametria (left side extension to S3 sacral root)—A Video Vignette

“…Natural orifice, segmental bowel resection and end-to-end colonic anastomosis was performed. The vagina was closed robotically, with a unidirectional, barbed suture and a biological mesh (Permacol™ Surgical Implant, Medtronic, Minneapolis, MN, USA) applied with the aim of reducing the risk of postoperative fistula [4].…”

Redo colorectal anastomosis for rectovaginal fistula following posterior pelvic exenteration – A video vignette

“…The patient developed an anastomotic leak with a rectovaginal communication. Rectovaginal fistulas are usually caused by accidental incorporation of the vaginal wall into the colorectal anastomosis while stapling [1][2][3]. Treatment options include diversion only, endoanal repair, pull-through, endoanal repair, endoscopy stent, and redo colorectal anastomosis [3].…”