Technique and results of the first six cases of anal sphincteroplasty with Deoti's flap for complex anatomical deformity of the perineum / Técnica e resultados dos primeiros seis casos de esfincteroplastia anal com retalho Deoti para deformidade anatômica complexa do períneo

ABSTRACT Objectives: Anal sphincteroplasty with Deoti's flap is a recently published procedure for the treatment of fecal incontinence with severe perineal deformity. The aim of this study is to report six cases of patients, analyzing their results in fecal incontinence questionnaires and proposing a new scale to better assess our technique's main objective, the reconstruction of the perianal anatomy. Methods: Six patients were submitted to anal sphincteroplasty with Deoti's flap and follow-up was performed every six months. Functional results and Quality of Life were measured by Wexner Score and Fecal Incontinence Quality of Life Scale, respectively. Results: All operations were carried out without failure to perform Deoti's flap rotation. The sample presented medians of 18.5 and 3.5 on Wexner Score, before and after surgery, respectively. In the Fecal Incontinence Quality of Life Scale, the medians before and after surgery are, respectively, 1.75 and 3.35 (Scale 1), 1.54 and 2.60 (Scale 2), 2.35 and 3.28 (Scale 3), 1.49 and 3.33 (Scale 4). The p-values were 0.0173 for Wexner Score and 0.0260, 0.0411, 0.0368 and 0.0952 for Scales 1, 2, 3 and 4 of Fecal Incontinence Quality of Life Scale, respectively. All patients presented sustained improvement in Wexner Score and in quality of life questionnaire (in all scales of Fecal Incontinence Quality of Life Scale). Conclusions: Deoti's surgical flap with sphincteroplasty successfully reconstructs complex anatomical deformities of the perineum. Current questionnaires to assess fecal incontinence may not evaluate properly the anatomical result of the technique, thus we propose a visual scale. In addition, sphincteroplasty with Deoti's flap may have longer-term outcomes in functional results than sphincteroplasty alone.

RESUMO Objetivos: A esfincteroplastia anal com retalho Deoti é um procedimento publicado recentemente para o tratamento de deformidade perineal grave. O objetivo deste estudo é relatar seis pacientes, analisando seus resultados em questionários de incontinência fecal e propondo uma nova escala para avaliar melhor o objetivo principal da nossa técnica, a reconstrução da anatomia perianal. Métodos: Seis pacientes foram submetidos à esfincteroplastia anal com retalho de Deoti e o acompanhamento foi realizado a cada seis meses. Os resultados funcionais e a qualidade de vida foram medidos pelas Escalas Wexner Score e FIQL, respectivamente. Resultados: Não houve falhas na rotação do retalho Deoti. A amostra apresentou medianas de 18,5 e 3,5 na Wexner Score, antes e depois da cirurgia, respectivamente. Na Escala FIQL, as medianas antes e depois da cirurgia são, respectivamente, 1,75 e 3,35 (Escala 1); 1,54 e 2,60 (Escala 2); 2,35 e 3,28 (Escala 3); 1,49 e 3,33 (Escala 4). Os valores de p foram 0,0173 para Wexner Score e 0,0260; 0,0411; 0,0368 e 0,0952 para Escalas 1; 2; 3 e 4 de FIQL, respectivamente. Todos os pacientes apresentaram melhora sustentada na pontuação de Wexner e no questionário de qualidade de vida (em todas as escalas do FIQL). Conclusões: O retalho de Deoti com esfincteroplastia reconstrói com sucesso as deformidades anatômicas complexas do períneo. Os questionários atuais para avaliar a incontinência fecal podem não avaliar adequadamente o resultado anatômico da técnica, por isso propomos uma escala visual. Além disso, a esfincteroplastia com retalho de Deoti pode apresentar resultados funcionais mais duradouros do que a esfincteroplastia isolada.

Hernias perineales / Perineal hernias

Introducción: Las hernias perineales son excepcionales y predominan ampliamente en el sexo femenino. Se clasifican en anteriores o posteriores según su localización con respecto al músculo transverso del periné. Etiológicamente pueden ser primarias (congénitas o adquiridas), de las cuales se han descrito alrededor de 100 casos, y secundarias sobre todo a operaciones previas (resección adbominoperineal). Objetivo: Actualizar los conocimientos sobre las hernias perineales por lo infrecuente de este padecimiento. Métodos: Se realizó una revisión bibliográfica a partir de la consulta de artículos relacionados con el tema, publicados en Pubmed, Hinari, SciELO y Medline mediante el localizador de información Endnote. Se utilizaron 51 citas para la revisión, 41 de ellas de los últimos cinco años. Se incluyeron tres libros y una cita del propio autor. Conclusiones: Las hernias perineales son extremadamente raras. Existe poca experiencia reportada en la bibliografía, por lo que aún no es posible determinar la mejor forma terapéutica. Pueden abordarse por vía abdominal, perineal o combinada. Las técnicas empleadas son: cierre simple, transposición de colgajos musculares, colocación de mallas y retroflexión del útero o vejiga para cerrar el defecto. Aunque no existe suficiente experiencia, la cirugía laparoscópica se ha utilizado en algunos casos y podría ser la vía de elección en el futuro(AU)

Introduction: Perineal hernias are exceptional and predominate widely in the female sex. They are classified into anterior or posterior, based on their location with respect to the transverse muscle of the perineum. Etiologically speaking, they can be primary (congenital or acquired), of which about 100 cases have been described, and secondary above all to previous operations (abdominoperineal resection). Objective: To update the knowledge about perineal hernias, due to the infrequent nature of this condition. Methods: A literature review was carried out in the articles about the topic and published in Pubmed, Hinari, SciELO and Medline using the Endnote information locator. We used 51 citations for the review, 41 of which belonged to the last five years. Three books and a citation by the author were included. Conclusions: Perineal hernias are extremely rare. There is little experience reported in the literature, so it is not yet possible to determine the best therapeutic form. They can be treated by an abdominal or perineal approach, or combined. The techniques used are: simple closure, transposition of muscle flaps, placement of meshes, and retro-flexion of the uterus or bladder to close the defect. Although there is not enough experience, laparoscopic surgery has been used in some cases and could be the gold standard in the future(AU)

Deoti surgical flap and sphincteroplasty for treatment of severe perineal deformity / Retalho cirúrgico de Deoti mais esfincteroplastia para tratamento de deformidade perineal grave

ABSTRACT Purpose: Anal incontinence is a very stigmatizing condition, which affects biopsychosocially the patient. It is a neglected, but quite common complication of obstetric and anorectal surgery, however it has treatment options. None of the treatment options have exceptional efficacy rates and still associated with risk of recurrence. The surgery techniques known are: anterior and posterior shortening procedure; post-anal repair; anterior elevator plasty and external sphincter plication; total pelvic floor repair and sphincter repair. None of them use a flap rotation of adipose tissue. The purpose is to propose a new surgery technique of anal sphincteroplasty, which uses flap rotation, for severe perineal deformity associated with anal incontinence. Methods: Patient with severe perineal deformity and anal incontinence treated with a new surgery technique of sphincteroplasty with flap rotation. Results: The severe perineal deformity was corrected with both esthetic and functional results. Anal continence measured by Wexner and Jorge assessment in a follow-up period of 2 years after the intervention. Pictures and video show esthetic and functional aspects. Conclusion: This is the first time that a flap rotation is used to treat a severe perineal deformity. And the technique presented promising outcomes, which allows perineum reconstruction that is similar to the original anatomy. Therefore, this technique is justified to better evaluate its efficiency and the impact on patients' prognosis.

RESUMO Objetivo: A incontinência anal é uma condição muito estigmatizante, que afeta biopsicossocialmente o paciente. É uma complicação negligenciada, mas bastante comum da cirurgia obstétrica e anorretal, no entanto, tem opções de tratamento. Nenhuma das opções de tratamento tem taxas de eficácia excepcionais e ainda está associada ao risco de recorrência. As técnicas cirúrgicas conhecidas são: procedimento de encurtamento anterior e posterior; reparação pós-anal; plástica do elevador anterior e plicatura externa do esfíncter; reparo total do assoalho pélvico e reparo do esfíncter. Nenhum deles utiliza uma rotação de retalho de tecido adiposo. O objetivo é propor uma nova técnica cirúrgica de esfincteroplastia anal, que utiliza a rotação de retalho, para deformidade perineal grave associada à incontinência anal. Métodos: Paciente com deformidade perineal grave e incontinência anal tratada com nova técnica cirúrgica de esfincteroplastia com rotação de retalho. Resultados: A deformidade perineal grave foi corrigida com resultados estéticos e funcionais. Continência anal medida pela avaliação de Wexner & Jorge em um período de seguimento de 2 anos após a intervenção. Imagens e vídeo mostram aspectos estéticos e funcionais. Conclusão: Esta é a primeira vez que uma rotação de retalho é usada para tratar uma deformidade perineal grave. E a técnica apresentou resultados promissores, o que permite a reconstrução do períneo semelhante à anatomia original. Portanto, esta técnica é justificada para melhor avaliar sua eficiência e o impacto no prognóstico dos pacientes.

Aspectos clínicos, cirúrgicos, histológicos e pós-operatórios de oito cadelas com leiomioma vaginal / Clinical, surgical, histological and postoperative aspects in the case of eight bitches with vaginal leiomyoma

O presente trabalho reporta as características clínicas e cirúrgicas de oito casos de cadelas portadoras de leiomioma vaginal, com histórico de aumento de volume na região perineal, aparecimento de massa pela vulva, disquezia, tenesmo e disúria. As pacientes foram submetidas à cirurgia de episiotomia para ressecção da massa neoplásica, e em quatro casos foi necessária a ovariossalpingo-histerectomia. Porém, uma delas apresentou recidiva, e, no segundo procedimento cirúrgico de exérese de neoformação, o histopatológico diagnosticou leiomiossarcoma. A paciente ainda apresentou mais duas recidivas, até o proprietário optar pela eutanásia. Decorridos quatro meses, as sete cadelas diagnosticadas com leiomioma não apresentaram recidiva, e os proprietários relataram ausência de sinais relacionados com a doença descrita. Conclui-se que a episiotomia para ressecção da massa vaginal e a ovariossalpingo-histerectomia nas cadelas inteiras nos casos de tumores vaginais benignos são tratamentos satisfatórios, com bom prognóstico, ao contrário do leiomiossarcoma.

This study reports the clinical and surgical procedures of eight cases of bitches with vaginal leiomyoma. All animals presented increased volume in the perineal region, and exteriorization of the vulva, dyschezia, tenesmus and dysuria. The patients underwent episiotomy surgery for resection of the neoplastic mass, and ovariosalpingohisterectomy in four cases. However, one had recurrence on the second surgical procedure for removal of neoformation, histopathological diagnosed leiomyosarcoma, the patient also had two more relapses, until the owner chose euthanasia. After four months, the seven dogs diagnosed with leiomyoma showed no recurrence and the owners reported no signs of the disease described. We concluded that episiotomy for vaginal mass resection combined with ovariohysterectomy in cases of benign vaginal tumors have shown satisfactory treatment with good prognostic.

Surco perineal en ginecología infantil: reporte de 2 casos clínicos / Perineal groove in pediatric gynecology: a report of 2 cases

Introduction: the perineal groove is a very uncommon anorectal anomaly. It is the result of an unknown embryology anomaly. The perineal groove is a wet sulcus extending from de fourchette to the anus. It is a benign pathology and tends to resolve spontaneously. Objective: We report two cases of girls diagnosed with perineal groove and their follow up. Cases reports: The first case is an 18 days old baby girl, that during her first clinical examination there was found a painless lineal lesion in the perineum from the fourchette to the anus, which created a big anxiety in her family. She was cared at the Pediatric Gynecology Unit, with local lubrication, doing well with the epithelization of it. The second case is an 8 year-old girl who consulted because, when being a child, she was diagnosed with a perineal lesion, but she didn't receive any special treatment and now she feels some aches in the perineum. Conclusions: The perineal groove is a benign entity pretty unknown by general practitioners or pediatricians. It is important to be up to date with this condition to avoid alarming misinterpretations.

Introducción. El surco perineal es una malformación poco frecuente, de etiología desconocida, consiste en una ranura en la línea media del periné desde la horquilla vulvar al ano, es benigna y tiende a la resolución espontánea. Objetivos: Reportar el diagnóstico y evolución de dos pacientes con surco perineal. Casos clínicos: Caso 1. Recién nacida de 18 días que previo al alta de maternidad se pesquisó una lesión lineal no dolorosa desde la horquilla vulvar al ano, lo que generó gran inquietud en su familia. En Ginecología Infantil se confirmó el diagnóstico, se manejó con lubricación del área genital evolucionando a la epitelización del surco. Caso 2. Niña de 8 años consultó por que en controles de salud se diagnosticó una "fisura" entre la horquilla vulvar y el ano que no fue tratada y presentaba molestias inespecíficas en el periné. Se indicó resección quirúrgica, pero paciente evolucionó satisfactoriamente con lubricación de la zona. Conclusiones. El surco perineal es una entidad benigna que debe ser conocida por médicos de atención ambulatoria debido a la alarma que pueden generar sus diagnósticos diferenciales.

Hipospadia perineal em um cão: relato de caso / Perineal hypospadias in a dog: case report

A hipospadia é uma anomalia congênita da genitália externa, na qual a uretra peniana termina ventral e caudalmente à sua abertura normal. Pode ser classificada, com base na localização da abertura uretral, como glandular, peniana, escrotal, perineal e anal. O objetivo deste trabalho é relatar um caso raro de hipospadia perineal, em que são abordados seus aspectos clínicos e terapêuticos, em um cão macho, sem raça definida, com seis meses de idade. Um canino com histórico de suspeita de hermafroditismo e presença de um orifício, logo abaixo do ânus, pelo qual urinava foi atendido no Hospital de Clínicas Veterinárias da Universidade Federal do Rio Grande do Sul (UFRGS). Durante o exame físico, foi observado o meato uretral localizado ventralmente ao ânus, além de alterações no prepúcio, pênis e escroto. Foram realizados exames de triagem, tais como: hemograma completo, urinálise, ecografia abdominal e uretrocistografia. O cão foi encaminhado para a cirurgia, quando foi submetido à amputação peniana e prepucial total e também à orquiectomia. O canino recebeu antibioticoterapia, analgésicos, anti-inflamatório e limpezas diárias dos pontos e da região perineal e apresentou excelente recuperação pós-operatória. Após 30 dias da cirurgia, o paciente retornou ao hospital, e foi verificada completa cicatrização da ferida cirúrgica, sem sinais de infecção urinária e inflamação ou assaduras na região perineal. A hipospadia perineal é um caso raro de anomalia uretral congênita, ainda pouco documentada em medicina veterinária. O procedimento cirúrgico realizado demonstrou ser importante, uma vez que removeu toda a genitália externa defeituosa, onde, futuramente, poderiam desenvolver-se infecções e/ou inflamações. Com isso, minimizou as complicações dessa doença e melhorou a qualidade de vida do paciente...

Hypospadias is a congenital anomaly of the external genitalia, where the penile urethra finishes its normal opening ventrally and caudally. It can be classified based on the location of the urethral opening as glandular, penile, scrotal, perineal and anal. The aim of this work was report an uncommon case of perineal hypospadias, working on the clinical and therapeutic aspects in a six-month-old male dog of undefined race. A dog with a history of suspected hermaphroditism and presenting a hole below the anus by which it urinated, was rescued at the Veterinary Teaching Hospital of the Federal University of Rio Grande do Sul (UFRGS). During the physical exam, it was observed that the urethral meatus was situated ventrally to the anus. Foreskin, penis and scrotum alterations were also seen on the dog. Screening exams such as complete blood count, urinalysis, abdominal ultrasound and cystourethrography were done. The dog went straight to surgery, where it had total penile and total preputial amputation and also orchiectomy. The canine showed excellent postoperative recovery, receiving antibiotic therapy, analgesics, anti-inflammatories and daily cleaning on stitches and the perineal region. Thirty days after surgery the patient went back to the Hospital presenting a complete healing of the surgical wound, without reporting signs of urinary infection and inflammation or rashes on the perineal region. The perineal hypospadias is a rare case of urethral congenital anomaly, still not well documented by veterinary medicine. The surgical procedure done demonstrated to be important, since there was the removal of all of the defective external genitalia where, in the future, inflammation and infection could develop, decreasing the complications of this disease and improving this patient's quality of life...

A rare case of perineal hamartoma associated with cryptorchidism and imperforate anus: case report / Caso raro de hamartoma perineal associado a criptorquidia e ânus imperfurado: relato de caso

A full-term male neonate with anorectal anomaly and external perineal anomalies was referred to our service. Physical examination showed an epithelized perineal mass with cutaneous orifices, which had urine fistulization, hipotrofic perineal musculature, bilateral congenital clubfoot, hipospadic urethra, criptorquidy bilateral with nonpalpable testis and imperforate anus. A colostomy was constructed immediately after birth. The child underwent excision of perineal mass, bilateral orchidopexy, Duplay neourethroplasty and coloanal anastomosis at 3 months of age. The histopathological examination of the perineal mass revealed a hamartoma.

Recém-nascido a termo do sexo masculino encaminhado ao nosso serviço por anomalia anorretal e anomalias perineais externas. O exame físico revelou massa perineal epitelizada, com orifícios cutâneos que apresentavam saída de urina, musculatura perineal hipotrófica, pé torto congênito bilateral, uretra hipospádica, criptorquidia bilateral com testículos não palpáveis e ânus imperfurado. Logo após o nascimento, o paciente foi submetido à colostomia. Aos 3 meses de idade, a criança foi submetida à excisão da massa perineal, orquidopexia bilateral, neouretroplastia a Duplay e anastomose coloanal. A análise anatomopatológica da massa perineal indicou hamartoma.

Perineal accessory scrotum.

A boy with perineal accessory scrotum but without any other congenital anomaly is being described. He presented with a rugose skin tag on a midline perineal mound and the diagnosis could be confirmed by the histological findings of subcutaneous smooth muscles. Other reports of perineal scrota have been reviewed and a simple classification has been proposed for such cases, based on the appearance of the accessory scrotum and the associated anomalies.

Perineal canal: an uncommon entity with good prognosis.

This article reports two patients with perineal canal (anovestibular fistula) who were treated at Dept. of Pediatric Surgery, LTMG Hospital, Mumbai. Both the patients had normal anus and a fistula between the anal canal and the vestibule. They were treated by vestibulo anal pull through procedure. The pathogenesis of this condition and the pertinent literature is reviewed.

Versatility of pedicled anterolateral thigh flap for the coverage of the inguinoscrotoperineal defect

The main nutrient vessel of the anterolateral thigh flap is the perforator originating from the descending branch of the lateral circumflex femoral artery [LCFA].it supplies a large area of skin on the anterolateral aspect of the thigh. We report here a case of wide inguinoscrotoperineal defect in a young male patient following a post necrotizing fascitis defect which was covered by a pedicled anterolateral thigh flap. The result was satisfactory. The anterolateral thigh flap has the advantage of a long vascular pedicle, large caliber vessels, availability of large skin flap area, and is also suitable as a pedicle, free or flow through flap

Caudal regression syndrome and peno-scrotal transposition

Caudal Regression Syndrome is a rare anomaly affecting different systems in the caudal portion of the fetus. Peno-scrotal transposition is a rare condition of variable severity often associated with Caudal Regression Syndrome. We report a case of Caudal Regression Syndrome with perineal ano-rectal duplication, incomplete peno-scrotal transposition, perineal hypospadias, chordee, and thoracic hemivertebrae

Bifid scrotum, perineal hamartoma and high imperforate anus: a case report

This is a case report of a newborn patient with imperforate anus, urethro-colonic fistula, perianal hamartoma, and bifid scrotum. Successful staged repair of these anomalies is described together with review of the embriology related to the case

Malformaciones anorrectales: diagnóstico y decisiones iniciales / Anorectal malformations: their diagnosis and the initial decisions

The author presents the salient aspects of anorectal malformation which allow us to simplify their anatomical diagnosis. In many cases only clinical means are used while in others adequate use of technical studies are necessary. This enables us to reach therapeutic decisions in the simplest and most orderly fashion so that patients with these anomalies may be given the opportunity of attaining normal or near normal function

Anormalidades del perine en el recien nacido

Es fundamental realizar la evaluacion completa del recién, incluyendo al área perineal, donde se pueden encontrar alteraciones frecuentes como fimosis, hidrocele comunicante o no, quiste de cordón, testiculos mal descendidos, malformaciones ano-rectales, fístulas recto-urinarias, tumores y otras malformaciones menos frecuentes. Algunas de ellas tienen significación vital en el recién nacido y otras requerirán una evaluación más completa