Persistent ischiorectal fistula secondary to rectal extrusion of posterior vaginal mesh: Case report.

INTRODUCTION AND HYPOTHESIS: Vaginal mesh has been used for years to try to improve the results of pelvic organ prolapse surgery, but current evidence does not confirm this improvement and instead describes serious and frequent adverse events. CLINICAL CASE: 64-year-old patient with rectal extrusion of posterior vaginal mesh placed 8 years earlier, and persistent left ischiorectal fistula refractory to surgery. She required 5 surgeries, carried out jointly between gynecology and general surgery, to solve, firstly, the bilateral perianal abscess secondary to extrusion of the posterior vaginal mesh into the rectum and then the persistent left ischiorectal fistula, despite the removal of the material prosthetic. Finally, the fistula was solved by injection of platelet-rich plasma. CONCLUSIONS: Vaginal mesh complications often need a multidisciplinary approach, and treatment may require multiple approaches and more than one surgical procedure. In the case of a persistent fistula refractory to surgery, after removing the mesh, non-invasive regenerative therapies that promote vascular growth and tissue regeneration could be considered such as platelet-rich plasma.

Pessary with perineal suture for treatment of pelvic organ prolapse: description and benefit of the technique.

INTRODUCTION AND HYPOTHESIS: Vaginal pessaries are used as a conservative treatment for POP in women who do not want or are not candidates for surgery, or as a preliminary step to surgery. Our goals are: evaluate the evolution of patients with advanced POP and repeated expulsion of the pessary, who underwent perineal suture to try to maintain the device. Describe the epidemiological characteristics of patients treated with pessaries in our environment, with or without perineal closure. METHODS: Observational, descriptive and prospective study (October 2016-March 2021) that includes 352 women with advanced-stage POP treated with a pessary, of which 55, after repeated expulsion of the pessary, were treated with a pessary and perineal suture. RESULTS: After pessary insertion associated with perineal closure, 26 patients (47.2%) expelled the pessary and underwent surgery, and 29 (52.8%) kept the device, avoiding surgery. Regarding the women who required perineal suture: The mean age was higher than in the group of patients who did not need this intervention (75.3 vs. 68.3 years), 94.5% had POP ≥ grade III and 100% had a perineal width > 2.5 cm. CONCLUSIONS: Treatment with pessary and perineal closure avoids surgery in women with advanced age and repeated expulsion. Although age should not be an independent factor that limits surgical treatment or the type of intervention, it would be useful to have scales to quantify the frailty of patients, being able to standardize perineal closure in elderly and/or frail women, and in those who do not want or have contraindications for surgery.

Normalized second and fourth finger lengths in male and female partners and IVF cycle outcomes.

RESEARCH QUESTION: Hox genes are involved in limb formation during normal embryological development. Their modulation by circulating maternal oestrogens and androgens determines the length of the second and fourth fingers of the adult hand. Do these same intrauterine hormone levels also determine fertility outcomes in the adult? DESIGN: To study the association between the length of the second and fourth fingers of both partners undergoing IVF (as a surrogate of their previous intrauterine exposure to oestrogens and androgens) with treatment outcome after IVF, data corresponding to 256 IVF cycles were analysed. Finger length was normalized to the individual height. RESULTS: In the female partner, a longer normalized second finger length of the left (2DLN) hand, reflecting a high intrauterine exposure to oestrogens, was independently and significantly (P = 0.011) associated with obtaining at least one top-quality embryo in a multivariate model. Conversely, in the male partner a longer normalized fourth finger length of the left hand (4DLN), reflecting a high intrauterine exposure to androgens, was independently and significantly (P = 0.032) associated with obtaining at least one top-quality embryo in the same multivariate model. In the female partner, 2DLN was inversely and significantly (P = 0.01) associated with achievement of pregnancy. CONCLUSIONS: Intrauterine exposure to high levels of oestrogens and androgens in females and males, respectively, predisposes to the production of higher-quality embryos under in-vitro conditions during adulthood. Paradoxically, this also seems to result in a lower pregnancy rate.