Rectovaginal fistula after Posterior Intravaginal Slingplasty and Polypropylene mesh augmented rectocele repair
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- Hilger, W.S. & Cornella, J.L. Int Urogynecol J (2006) 17: 89. doi:10.1007/s00192-005-1354-x
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Posterior Intravaginal Slingplasty and mesh augmented rectocele repairs are procedures promoted for correction of vaginal relaxation. There is little data on the complications of these procedures alone or in combination. The first report of rectovaginal fistula after Posterior Intravaginal Slingplasty with graft augmented rectocele repair is presented. A 60-year-old female developed a rectovaginal fistula 3 months after undergoing a Posterior Intravaginal Slingplasty and mesh augmented rectocele repair for prolapse. Two attempts at correcting the fistula failed and there was a recurrence of her vault prolapse. She may now require diverting colostomy and repeat repair of her vault prolapse. The case report highlights the difficulties in treating a rectovaginal fistula that developed after Posterior Intravaginal Slingplasty and mesh augmented rectocele repair for vaginal vault prolapse. More data regarding complications associated with use of these procedures is needed prior to widespread use.
Posterior Intravaginal Slingplasty (Posterior IVS) has been proposed as a procedure for vaginal vault prolapse [1, 2]. There is limited data on the safety and efficacy of this procedure used alone or in combination with other graft materials for prolapse repair. The first report of rectovaginal fistula after Posterior Intravaginal Slingplasty with graft augmented rectocele repair is presented.
This patient was a 60-year-old female who presented to our clinic with complaints of anal discharge, vaginal discharge and dyspareunia. Approximately 3 months prior to her visit she had undergone an anterior colporrhaphy, transobturator sling, posterior colpoperineorrhaphy with polypropylene mesh reinforcement, Posterior IVS and perineoplasty for vaginal vault prolapse and stress incontinence at an outside institution.
The original posterior colporrhaphy was performed by dissecting the posterior vaginal mucosa laterally on both sides, plicating the levator fascia and attaching the polypropylene mesh to the lateral edge at the highest point of the rectocele bilaterally with 0-vicryl suture. The size of the mesh was not indicated. The IVS procedure was then performed and the operative note states the tunneler trocar was taken to the level of the ischial spine, turned 45° medially, passed through the iliococcygeus muscle and into the vagina. The mesh was attached to the multifilament polypropylene IVS tape with 0-vicryl suture after it had been placed. The remainder of the mesh was fixed to the lateral edges of the levator musculature bilaterally. Although the operative note states that care was taken to avoid hemorrhoidal vessels during passage of the IVS device, a rectal exam was not indicated. The patient was discharged on postoperative day two.
Three weeks after surgery the patient presented with vaginal discharge, fever and chills and was treated as an outpatient with oral antibiotics. Three days later, she had bilateral perianal lumps that were tender and draining. Examination revealed a 3×2 cm area of induration on the right perianal area that was firm, tender and draining from the operative incision. The left perianal area was tender but there was no induration or drainage. The perineum was intact. The patient was treated with IV antibiotics for 2 days and released.
The patient presented to our clinic 3 months after her procedure complaining of vaginal and rectal drainage and dyspareunia. On exam mesh material was felt in the rectum just proximal to the external anal sphincter. There was a mild bulge higher in the vagina and the perineum was intact but at 6 o‘clock there was a ridge of firm vaginal mucosa noted that correlated with where the mesh had eroded through the rectal mucosa. There was no erythema noted in the vagina.
Proctoscopy exam revealed mesh protruding in the rectum just above the dentate line at 12 o’clock. The protruding mesh was resected in the office with an anoscope and scissors. One month later the patient began to experience increased vaginal discharge with bowel movements. A vaginogram confirmed a rectovaginal fistula and an anoscope exam noted a small dimple above the dentate line but no protruding mesh.
The patient recovered without difficulty but noted recurrence of the vaginal discharge approximately 7 weeks later. An examination by the colorectal surgeons revealed a fistula 2 cm from the anal verge. The patient underwent a transanal repair with mucosal advancement flap. Intraoperatively the fistula was noted to be at the distal rectum at the site of the dentate line. It was 3 mm in size.
Approximately 2 weeks after the advancement procedure the patient noted stool and gas passing from the vagina. An examination confirmed the persistence of the rectovaginal fistula and a recurrent enterocele was noted as well. The patient is currently undergoing conservative management in an effort to let the fistula mature. Re-operation and diverting colostomy are being considered.
This is the first case reported of rectovaginal fistula after Posterior Intravaginal Slingplasty with polypropylene augmented rectocele repair. Medline review of the literature (1966–2005) using key words “vaginal prolapse”, “rectovaginal fistula” and “surgical mesh” provided no published case reports. A review of the Manufacturer and User Facility Device Experience Database (MAUDE) (http://www.fda.gov/cdrh/) revealed one case of possible rectovaginal fistula associated with the Posterior IVS device. In addition there were 3 cases of infection 2 treated with antibiotics alone and one requiring antibiotics and removal of the mesh. There was also one rectovaginal fistula case and 14 cases of vaginal erosion reported with use of mesh.
There is data published on the use of synthetic mesh for rectocele repair. Sullivan et al reported on 236 patients a median 5.3 years after total vault repair with mesh and noted that 10% required surgical intervention for complication of the repair . Others have noted a 12.9% incidence of vaginal mesh erosion when a vicryl-prolene mesh was used with posterior colporrhaphy but this it was dealt with in an outpatient setting . When Mersilene mesh is placed vaginally and passed into the peritoneal cavity for sacralcolpoperineopexy erosion rates have been noted as high as 40% . One study looking at a monofilament polypropylene mesh placed in the anterior and posterior compartment found an overall 9% erosion rate and one patient who developed a rectovaginal fistula . Given that there is no proven benefit to the use of mesh versus traditional posterior colporrhaphy and given these high rates of erosion, it has been advised that the use of synthetic mesh in the posterior vagina should be approached with caution .
There are only two published case series looking at the safety and efficacy of the Posterior IVS for vaginal vault prolapse. One author noted an erosion rate of 5.3% and two rectal perforations but all were treated conservatively . The multifilament polypropylene tape used with the IVS device has been noted to have a significantly higher erosion rate than the monofilament polypropylene tape used in urethropexy for stress urinary incontinence . Further studies on the use of this device for vault prolapse will help better define the safety and clinical utility.
We cannot say with certainty why the rectovaginal fistula developed in this patient. The outside operative report noted an attempt to avoid hemorrhoidal vessels during trocar placement but a rectal exam to check for perforation was not noted. However, the fact that the patient presented with complaints approximately 3 months later makes it more likely that this was an erosion over time rather then an acute perforation of the rectum with the trocar. The patient had no medical comorbidities such as diabetes or those requiring steroid use that may effect tissue healing. Although initially the polypropylene mesh was noted to be protruding into the rectum in the office, when the fistula tract was dissected both meshes were noted to be at the fistula site making either mesh culpable. Finally, the patient had a postoperative infection associated with her repair which may have placed her at higher risk for mesh erosion.
The use of mesh in prolapse surgery has been promoted recently with little data to support its safety and efficacy . We report on a serious complication which can arise from erosion of the material into the surrounding viscera and the difficulty in treating patients with mesh in the vagina. Careful review of indications for and use of synthetic mesh for vaginal prolapse should be performed prior to widespread use.