Could robotic-assisted surgery reduce mesh-related complications after ventral mesh rectopexy? Experience of a tertiary centre and systematic review of the literature.

AIM: The development of robotic assistance has made dissection and suturing in the deep pelvis much easier. The augmented quality of the images and the articulation of the robotic arms have also enabled a more precise dissection. The aim of this study is to present the data on robotic-assisted ventral mesh rectopexy procedures in a university hospital and examine the literature in terms of mesh erosion. METHOD: The electronic databases Pubmed, Embase and Cochrane were searched. Studies from January 2004 until January 2023 in the English language were included. Studies which included fewer than 10 patients were excluded. Laparoscopic or robotic-assisted ventral mesh rectopexies were included. Mesh erosion rates following laparoscopic or robotic-assisted ventral mesh rectopexies were measured. RESULTS: Overall, the systematic review presents 5911 patients from 43 studies who underwent laparoscopic ventral mesh rectopexy compared with 746 patients treated with robotic-assisted ventral mesh rectopexy from six studies and our centre. Mesh erosion was rare in both groups; however, the prevalence was greater in the laparoscopy group (0.90% vs. 0.27%). CONCLUSION: The mesh erosion rates are very low with robotic-assisted ventral mesh rectopexy. For precise results, more studies and experience in robotic surgery are required.

Robot-assisted pelvic floor reconstructive surgery: an international Delphi study of expert users.

BACKGROUND: Robotic surgery has gained popularity for the reconstruction of pelvic floor defects. Nonetheless, there is no evidence that robot-assisted reconstructive surgery is either appropriate or superior to standard laparoscopy for the performance of pelvic floor reconstructive procedures or that it is sustainable. The aim of this project was to address the proper role of robotic pelvic floor reconstructive procedures using expert opinion. METHODS: We set up an international, multidisciplinary group of 26 experts to participate in a Delphi process on robotics as applied to pelvic floor reconstructive surgery. The group comprised urogynecologists, urologists, and colorectal surgeons with long-term experience in the performance of pelvic floor reconstructive procedures and with the use of the robot, who were identified primarily based on peer-reviewed publications. Two rounds of the Delphi process were conducted. The first included 63 statements pertaining to surgeons' characteristics, general questions, indications, surgical technique, and future-oriented questions. A second round including 20 statements was used to reassess those statements where borderline agreement was obtained during the first round. The final step consisted of a face-to-face meeting with all participants to present and discuss the results of the analysis. RESULTS: The 26 experts agreed that robotics is a suitable indication for pelvic floor reconstructive surgery because of the significant technical advantages that it confers relative to standard laparoscopy. Experts considered these advantages particularly important for the execution of complex reconstructive procedures, although the benefits can be found also during less challenging cases. The experts considered the robot safe and effective for pelvic floor reconstruction and generally thought that the additional costs are offset by the increased surgical efficacy. CONCLUSION: Robotics is a suitable choice for pelvic reconstruction, but this Delphi initiative calls for more research to objectively assess the specific settings where robotic surgery would provide the most benefit.

Long-term outcomes of high-volume stapled hemorroidopexy to treat symptomatic hemorrhoidal disease.

PURPOSE: The study aimed to assess the long-term results of the stapled hemorrhoidopexy (SH) using high-volume devices equipped with innovative technology, evaluating recurrence rate, complications rate, and patients' satisfaction. METHODS: All the patients who underwent SH using high-volume devices (TST Starr plus, Touchstone International Medical Science Corp., Ltd.) for II to IV symptomatic hemorrhoidal disease from November 2012 to December 2014 were enrolled. Between December 2019 and January 2020, all of them were phone called to come to undergo a proctological reevaluation and asked to fill some questionnaires about hemorrhoidal prolapse recurrence, symptoms recurrence, and surgery satisfaction. RESULTS: Fifty-nine patients with a mean age of 47 years completely answered the questionnaires. Twenty-two of them accepted to come to undergo a proctological reevaluation while 27 preferred to answer only by phone due to their referred wellbeing. The median follow-up was 70.5 months (range, 60-84 months). The recurrence rate was 5.1% with a mean satisfaction level after surgery was 9.1 (range, 0-10) and 84.7% of patients whose satisfaction scored ≥8. The mean value of Cleveland Global Quality of Life assessment was 0.79 (range, 0.71-0.93). There were no cases of new onset of impaired anal continence after surgery. CONCLUSION: The new generation high-volume devices to perform SH resulted to be safe and effective for II to IV degree hemorrhoidal prolapse leading to a lower long-term recurrence rate with an evident reduction of postoperative complications in comparison with the low-volume SH.

Modified robotic ventral rectopexy with folded single titanized mesh suspension for the treatment of complex pelvic organ prolapse.

AIM: The incidence of complex pelvic organ prolapse in female patients is about 38%, and this disorder entails social and sexual restrictions. Treatment for this disorder is complex because it can enhance other, latent, problems. The aim of the present study is to describe a new robotic-assisted technique to simultaneously treat prolapses of different compartments with the use of a single titanized polypropylene mesh. METHOD: All patients referred from January 2018 to March 2019 to the Proctologic and Pelvic Floor Clinical Centre who were affected by complex pelvic organ prolapse underwent modified robotic ventral rectopexy with a folded single mesh (RVR-FSM). The anatomical and functional outcomes were respectively evaluated using the Pelvic Organ Prolapse Quantification (POP-Q) grading system and Wexner scores of constipation and incontinence. The satisfaction rate was investigated using a five-point scale (1 = not satisfied to 5 = extremely satisfied). RESULTS: Twenty-two women underwent RVR-FSM with a homogeneous follow-up of 12 months. The mean total operation time was 148 min, without any robot-related or other intraoperative complications. No mesh-related complications occurred. The POP-Q grade improved for every patient, with complete resolution of bulging symptoms in 21 patients (95.4%) at 1 year of follow-up. The Wexner constipation score showed a significant improvement, while the incontinence score slightly improved at 1 year after surgery. CONCLUSION: The use of a single mesh that can be folded was shown to provide significant improvement in functional and anatomical results associated with patient satisfaction. The robotic approach allows surgeons to perform an easier procedure with correct and deep mesh fixation.

Does Proctologic Surgery Really Influence Sexual Behaviors?

INTRODUCTION: The percentage of the heterosexual population that has experienced and regularly has anal intercourse ranges from 20% to 35% in the USA. This practice increases to 95% in certain populations, including lesbian, gay, bisexual, and transgender people. Due to the lack of data in the literature about the effect of proctologic surgery on anal intercourse, this study aimed to assess the impact of this surgery on sexual behavior in both genders. MATERIALS AND METHODS: From March 2016 to February 2018, an anonymous questionnaire was submitted to all patients aged >18 who had undergone proctologic surgery in one of two surgical units at tertiary referral centers and was assessed independently of gender. The exclusion criteria were incomplete healing and <3 months follow-up. RESULTS: In total, 929 patients answered the questionnaire in full. The overall prevalence of preoperative anal intercourse was 22.5%. The rate of anal intercourse among men was 16.7%, while among women, it was 28.9%. The overall postoperative rate of anal intercourse was 11.8%. The rate of postoperative anal intercourse among those who regularly engaged in anal intercourse preoperatively was 52.6%, with a 47.4% rate of non-completion (p <0.0001). The experiences reported during intercourse after surgery were mainly pain, stiffness, and partner discomfort. CONCLUSION: Considering the statistically significant postoperative AI abandonment rate following all types of proctologic surgery, the surgeon has a duty to both treat the disease and to inform the patient about the possible consequences regarding its influence on anal intercourse.

Advantages of robotic surgery in the treatment of complex pelvic organs prolapse.

Robot-assisted surgery is safe and effective to treat the complex pelvic organs prolapse (C-POP). The present study analyzes all the robotic procedures and their advantages in the treatment of C-POP performed in a Proctologic and Pelvic Floor Clinical Centre. All the patients affected by C-POP who had robot-assisted surgery were retrospective analyzed. The anatomical and functional outcomes were respectively evaluated through POP-Q grading system and Wexner score about constipation and incontinence. The satisfaction rate was investigated using a five-point scale. From September 2014 to December 2018, 229 women underwent robotic surgery. The follow-up was 12 months. There were no robot-related complications. One hematoma (4.5%) of the recto-vaginal space occurred after Robotic Ventral Rectopexy with Folded Mesh (R-VRP-FM). In the robotic assisted lateral suspension (R-ALS) group there was one case of anterior vaginal wall mesh exposure (0.9%). After the robotic ventral rectopexy (R-VRP) the recurrence rate of external rectal prolapse, internal rectal prolapse, rectocele and enterocele was respectively 6.6, 9.5, 7.4 and 9.5%. After R-VRP-FM only one cystocele (14%) and one partial rectal prolapse (25%) recurred. Vaginal bulge symptoms resolution rate was 95.4%. The mean Wexner constipation score significantly decreased after R-VRP and R-VRP-FM. Vaginal bulge symptoms improved in 98.3% of cases with any apical prolapse recurrence after robotic abdominal colposacropexy. Success rate after R-ALS was 99.1% and 96.4% for apical and anterior prolapse respectively. Robotic assistance makes some surgical steps easier and more precise and this may result in less morbidity and better results.

Stapled Surgery for Hemorrhoidal Prolapse: From the Beginning to Modern Times.

INTRODUCTION: Hemorrhoidal disease is the most common proctologic condition in adults. Among the different surgical procedures, one of the greatest innovations is represented by the stapled hemorrhoidopexy. The history of this technique started with a single stapler use passing through a double stapler technique to resect the adequate amount of prolapse, finally coming to the use of high volume devices. METHODS: Nevertheless, each device has its own specific feature, the stapler is basically made up with one or more circular lines of titanium staples whose height may be variable. The procedure is based on different steps: Introduction of the CAD, evaluation of the prolapse, fashioning purse string or parachute suture, the introduction of the stapler head beyond the suture, pull the wires through the window, close the stapler and keep pulled the wires of the suture held together with forceps, fire using two hands, open the stapler and remove it and check the staple line and then check the specimen. One of the latest innovations in stapled surgery is Tissue Selective Therapy. It is a minimally invasive procedure in which there is a partial circular stapled hemorrhoidopexy focused on the prolapsing piles with bridges of normal mucosa left. RESULTS: Several studies have reported that SH is a safe and effective procedure to treat hemorrhoidal prolapse. It is a quicker procedure with a shorter hospital stay and earlier return to work if compared with the conventional treatment. This is due to less postoperative pain, postoperative bleeding, wound complications and constipation. Furthermore, the first generation devices had worse outcomes if compared with those of the new generation stapler that showed lower postoperative complication rates with better anatomical and symptomatic results. CONCLUSION: Stapled procedure for the treatment of symptomatic hemorrhoidal prolapse represents one of the most important innovations in proctology of the last century bringing with it the new revolutionary concept of the rectal intussusception as a determining factor involved in the natural history of the disease. Stapled hemorrhoidopexy marked an era in which the surgeon may offer the patients a safe, effective treatment with less pain and fast recovery.

Improvement in Hemorrhoidal Disease Surgery Outcomes Using a New Anatomical/Clinical-Therapeutic Classification (A/CTC).

Introduction The introduction and diffusion of new techniques for hemorrhoidal surgery have made it clear how much Goligher classification is inadequate in the modern times, lacking in any correlation between anatomical and clinical features to a surgical procedure. The aim of the study was to evaluate if the application of a new classification of hemorrhoidal diseases might lead to an improvement in the postoperative surgical outcomes. Methods From January 2014 to December 2015, all patients undergoing surgery for hemorrhoidal disease were enrolled. The procedures performed were based upon a new anatomical/clinical-therapeutic classification (A/CTC) considering these items: anatomical presentation, symptom types and frequency, associated diseases, and available surgical treatments and their related contraindications. The new classification identified four groups: A (outpatient), B, C, and D (surgical approaches). The overall outcomes were assessed and then stratified by surgical groups. These data were then analyzed in comparison with the published data about all the surgical procedures performed. Results A total of 381 patients underwent surgery and they were stratified as follows: Group B (39), C (202), and D (140). Group B underwent Doppler-guided dearterialization with mucopexies or tissue selective therapy, Group C stapled procedures, and Group D hemorrhoidectomy. The mean follow-up was 30 months. The overall outcomes were: success rate 92.4%, recurrences 7.6%, postoperative complications 4.8%, long-term complications 5.4%, and reoperation rate 2.7%. The success rates stratified by groups were: B, 85%); C, 91.4%; and D, 95.7%. Conclusion The A/CTC proved to be useful in stratifying the patients and choosing the proper treatment for each case. This classification seems to improve the outcome of different surgical procedures if compared with those already published.

Complex pelvic organ prolapse: decision-making algorithm.

PURPOSE: The pelvic floor is considered as a single anatomical and functional unit, consisting of several structures that suspend the pelvic organs maintaining their function. For this reason, a multi-compartmental prolapse is a common disease that needs a multidisciplinary pelvic floor team in order to be treated. The aim of the authors is to suggest a treatment algorithm to better approach complex pelvic organ prolapse. METHODS: A multidisciplinary pelvic floor team was set up 7 years ago. Starting from the literature review integrated with a team experience, a decision-making algorithm was drawn up. It was used to guide all the shared treatment for the complex pelvic floor disorders. RESULTS: An accurate preoperative assessment with a shared diagnosis among the specialist is the base to follow the proposed algorithm. It leads to combine different surgical procedures considering advantages and disadvantages which may have an influence on the final outcome. CONCLUSIONS: The proposed algorithm provides an integrated surgical view of complex pelvic floor disorders. It shows how is it feasible to associate surgical treatments of different compartments to obtain good pelvic floor anatomical and functional results and leading to an improvement of the patients' quality of life.

Internal Delorme's Procedure for Treating ODS Associated With Impaired Anal Continence.

OBJECTIVE: The aim of this study was to evaluate the medium-term outcomes of internal Delorme's procedure for treating obstructed defecation syndrome (ODS) patients with impaired anal continence. PATIENTS AND METHODS: In a retrospective study, 41 ODS patients who underwent internal Delorme's procedure between 2011 and 2015 were divided into 3 subgroups according to their associated symptoms of impaired continence, as urgency, passive fecal incontinence and both, before study. Then the patients' preoperative statuses, perioperative complications, and postoperative outcomes were investigated and collected from standardized questionnaires, including Altomare ODS score, Fecal Incontinence Severity Index (FISI), Patient Assessment of Constipation-Quality of Life Questionnaire (PAC-QoL), and Fecal Incontinence Quality of Life Scale (FIQLS). All results with a 2-tailed P < .05 were considered statistically significant. RESULTS: At an average 2.8 years of follow-up, there were significant improvements ( P < .01) in Altomare ODS score, FISI, PAC-QoL, and FIQLS in all patients when comparing scores from before the operation with those at the final follow-up. Similar results were also observed in both the urgency subgroup and passive fecal incontinence subgroup, but there were no statistically significant improvements ( P > .05) in Altomare ODS score, FISI, PAC-QoL, or FIQLS in the urgency and passive fecal incontinence subgroups. Anorectal manometry showed the mean value of anal resting pressure increased 20%. Additionally, no major complications occurred. CONCLUSION: Internal Delorme's procedure is effective without major morbidity for treating ODS associated with urgency or passive fecal incontinence, but it may be less effective for treating ODS associated with both urgency and passive fecal incontinence.

Mucocele complicating stapled hemorrhoidopexy.

INTRODUCTION: Stapled hemorrhoidopexy is a safe and effective treatment for circumferential hemorrhoidal prolapse. The overall rate of complications ranges from 12,7% to 36,4% and the surgeon should be aware about their early identification and adequate treatment. PRESENTATION OF CASE: Female patient, 57 years was treated with stapled hemorrhoidopexy. Two years after surgery she reported to our center the occurrence of perineal discomfort, anal spasm and tenesmus. The anal exploration showed a bulge of the right lateral wall of the rectum at the level of stapled line without any related pain. 3D 360° transanal ultrasound showed a pararectal fluid collection. A surgical operation was performed and a great amount of mucus was drained. After one year the patient is completely asymptomatic with normal defecation. DISCUSSION: Mucocele is a rare complication which usually occurs after months from the operation and it is considered a variant of rectal pocket and it is usually completely separated from the rectal lumen at the level of stapled line. The differential diagnosis between mucocele and pararectal lesions, especially abscess may be often difficult. Surgery is the treatment of choice with a transanal approach that is generally preferred to the trans-perineal. CONCLUSION: Mucocele is a rare complication of stapled hemorrhoidopexy that may remain asymptomatic for a long period. In case of perineal discomfort after stapled procedure the physical examination combined with 3D 360° transanal ultrasound is necessary to reach the diagnosis. The knowledge of the possible rare complications is at the base of a correct treatment.

A rare case of leiomyoma of the internal anal sphincter.

INTRODUCTION: Leiomyoma is a benign tumour which derives from the smooth muscle fibres and it may occurs in every site in which this type of muscle is present. Among all benign soft tissue tumours it represents almost 3.8% and its pathogenesis remains still unknown. PRESENTATION OF CASE: The present case is about a 62year old woman referred to our centre complaining anal and perineal pain which increase after defecation in association with the appearance of a nodule in the perianal region fixed to the anal sphincter. A 360° tridimensional transanal ultrasound was performed and it showed an anterior nodular thickening of the internal anal sphincter. After an inconclusive preoperative biopsy and a counselling with the patient, the surgeons decided to proceed with the surgical excision. The immunohistochemical examination confirmed the preoperative suspicion of leiomyoma. At 1year follow-up the patient had not tumour-related symptoms or fecal incontinence and any signs of local recurrence at ultrasound imaging were demonstrated. DISCUSSION: Leiomyomas are relatively insensitive to chemotherapy whereby surgery is the treatment of choice and it should be adequate to the site and dimension of the lesion achieving a complete resection with free margins. A further close follow-up is needed too. CONCLUSION: Nowadays there is not a gold standard technique to treat such kind of lesions and the decision of the best surgical approach should depend on the dimension and site. In fact, surgery aims to the oncological outcome trying also to minimize the possible post-operative functional complications.

Persistent anal and pelvic floor pain after PPH and STARR: surgical management of the fixed scar staple line.

BACKGROUND: Persistent anal pain (PAP) after stapled procedures, be it hemorrhoidopexy (PPH) or stapled transanal rectal resection (STARR) may be hardly resolved by medical therapy. The typical objective finding in these patients is the staple line characterized by fixed scar to underlying layers. METHODS: A total of 21 consecutive patients were operated for PAP after stapled procedure. The scarred staple line was excised and detached from layers below, the mucosal continuity reconstructed by single stitches. From January 2003 to December 2013 1500 patients underwent stapled procedure. Of these patients treated in our unit, 9 (0.6 %) were operated for chronic anal pain and 12 were referred to our center from other hospitals. RESULTS: Fifteen (71.4 %) patients resolved and do not take any drugs for pain; an overall of 85.7 % (18/21) improved their clinical status. Mean time between the beginning of symptoms and the operation was 4.27 months (range 1-18 months). We divided the patients into three groups: before 3 months, between 3 and 6 months and after 6 months from the beginning of symptoms to the operation. The best results were in the first group with 100 % pain relief and satisfactory functional results. CONCLUSIONS: The relief of PAP after stapled procedure, in which we recognize a scarred and fixed staple line, depends by the early recognition of this typical finding. The authors suggest the surgical treatment not later than 3-6 months after the onset of symptoms to achieve the best results.

Quality-of-life impairment after endoluminal locoregional resection and laparoscopic total mesorectal excision.

BACKGROUND: For selected patients with rectal cancer, endoluminal locoregional resection (ELRR) by transanal endoscopic microsurgery (TEM) may be an alternative treatment option to laparoscopic total mesorectal excision (LTME). Few data are available on quality of life (QoL) after LTME and TEM. This study aimed to compare short- and medium-term QoL for T1 rectal cancer patients undergoing LTME or ELRR by TEM. METHODS: This study investigated 35 patients with T1N0 rectal cancer who underwent TEM (n = 17) or LTME (n = 18). Quality of life was evaluated by European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-C38 questionnaires preoperatively and then 1, 6, and 12 months after surgery. RESULTS: Observation 1 month after LTME showed worsening in all items of both questionnaires. After ELRR, the QLQ-CR38 showed worsening of gastrointestinal (p = 0.005) and defecation problems (p = 0.001), and the QLQ-C30 showed worsening of global health status (p = 0.014), physical functioning (p = 0.02) role functioning (p = 0.003), fatigue (p = 0.002), and pain (p = 0.001). The QLQ-CR38 6 months after LTME showed worsening of body image (p = 0.009), micturition (p = 0.035), and gastrointestinal problems (p = 0.011), and the QLQ-C30 showed worsening of physical functioning (p = 0.003), role functioning (p = 0.002), fatigue (p = 0.004), and nausea/vomiting (p = 0.030). After ELRR, neither the QLQ-CR38 nor the QLQ-C30 questionnaire showed any worsening but demonstrated improvement in global health status and physical functioning. The QLQ-CR38 12 months after LTME showed significant improvement in defecation problems (p = 0.004) and weight loss (p = 0.003), and the QLQ-C30 showed significant improvement in global health status (p = 0.001), nausea and vomiting (p = 0.003), and pain (p = 0.005). After ELRR, the QLQ-C30 showed improvement in emotional functioning (p = 0.012), whereas no significant difference was observed by the QLQ-C38. CONCLUSIONS: Functional sequelae are present up to 1 month only after ELRR by TEM and up to 6 months after LTME. At 12 months, neither procedure showed a significant difference in QoL compared with preoperative status.

Laparoscopic transperitoneal anterior adrenalectomy.

AIM: Aim of this study was to report the authors' experience with the anterior transperitoneal approach, and with an anterior submesocolic approach in case of left sided lesions. MATERIAL AND METHODS: From January 1994 to January 2011, 122 males and 170 females with a mean age of 50.7 years (range: 19-84) underwent laparoscopic adrenalectomy (LA) at 2 centers in Ancona and Rome (Italy) (that follow the same protocol). Fifteen patients underwent bilateral LA, the anterior transperitoneal approach was used in 233 cases (79.8%) and the anterior submesocolic in 59 (20.2%). One hundred and two patients had Conn's syndrome, 51 miscellaneous lesions, 55 Cushing's syndrome, 47 incidentalomas, 46 pheochromocytoma, 2 metastatic masses, 2 myelolipomas and 2 adrenogenital syndromes. The lesions had a mean diameter of 3.24 cm (range: 0.5-10). RESULTS: Mean operating time was 120 minutes (range: 30-390). Conversion to open surgery was required in 13 cases (4,45%). Blood pressure and heart rate were stable during the operation. There were 5 major complications. Mobilization and resumption of diet occurred on the first postoperative day. Mean hospital stay was 4.32 days (range: 2-30). DISCUSSION: Early identification and ligature of the adrenal vein, with minimal gland manipulation, are the major advantages, especially in case of pheochromocytoma. CONCLUSIONS: Adrenal masses can be successfully treated using a laparoscopic transperitoneal anterior approach, in presence of a suitable anesthesiological and surgical team's experience. KEY WORDS: Adrenal tumors, Laparoscopic adrenalectomy, Pheochromocytoma.

Nucleotide-guided mesorectal excision combined with endoluminal locoregional resection by transanal endoscopic microsurgery in the treatment of rectal tumors: technique and preliminary results.

BACKGROUND: Endoluminal locoregional resection (ELRR) by transanal endoscopic microsurgery (TEM) is an alternative treatment option for T1N0 rectal cancer and for selected patients with small T2N0 rectal cancer after neoadjuvant radiochemotherapy (n-RCT). The N parameter may remain undefined after transanal surgery. This study aimed to evaluate the role of a modified sentinel lymph node technique to improve N staging that the authors named "nucleotide-guided mesorectal excision" (NGME). METHODS: The study enrolled 41 patients (24 men and 17 women) with a mean age of 70.5 years. Preoperative staging identified dysplasia with no suspicion for cancer at imaging (n = 8), dysplasia with suspected malignancy at imaging (n = 15), no suspicion of malignancy at imaging after n-RCT (n = 2), cT1N0 (n = 6), cT2N0 (n = 6), cT3N0 (n = 3), and cT3N1 (n = 1). The patients underwent ELRR by TEM with NGME. Before surgery, 99m-technetium-marked nanocolloid was injected into the peritumoral submucosa. After resection, the residual defect was probed to detect residual radioactivity. If present, hot mesorectal fat was excised. RESULTS: With NGME, the mesorectal lymph node harvest increased from 0 to 10. Lymph nodes were isolated in the specimen or in hot mesorectal fat of 20 patients, 8 of whom had undergone n-RCT. The mean lymph node harvest was 2.75 ± 3.01 (range 1-10) in the irradiated patients and 2.91 ± 1.62 (range 1-6) in the nonirradiated patients (p = 0.87). The average number of lymph nodes in the irradiated patients was higher than in a previous historical series. CONCLUSIONS: The use of NGME during ELRR by TEM increases the lymph node harvest and may improve staging accuracy after transanal surgery.

Minimally invasive treatment of rectovaginal fistula.

BACKGROUND: Rectovaginal fistulas (RVFs) are a rare surgical condition. Their treatment is extremely difficult, and no standard surgical technique is accepted worldwide. This report describes a new approach using transanal endoscopic microsurgery (TEM) to treat RVFs. METHODS: A retrospective review of 13 patients who underwent repair of rectovaginal fistula using TEM between 2001 and 2008 was undertaken. The surgical technique is widely described, and the advantages of the endorectal approach are noted. RESULTS: The median follow-up period was 25 months, and the median age of the patients was 44 years (range, 25-70 years). The mean operative time was 130 min (range, 90-150 min), and the hospital stay was 5 days (range, 3-8 days). One patient experienced recurrence. This patient underwent reoperation with TEM and experienced re-recurrence. Two patients had minor complications (hematoma of the septum and abscess of the septum), which were treated with medical therapy. For two patients, a moderate sphincter hypotonia was registered. CONCLUSIONS: A new technique for treating RVFs using TEM is presented. The authors strongly recommend this approach that avoids any incision of the perineal area, which is very painful and can damage sphincter functions.