Rectoneovaginoplasty in a 32-year-old female with proximal vaginal agenesis and rectovestibular fistula: a rare case report.

Introduction and importance: Rectovestibular fistula with vaginal agenesis is a rare congenital anomaly, usually diagnosed during infancy. Adult presentation is exceptional, particularly in low-resource settings. While bowel segments are commonly used for neovaginal reconstruction, this case explores an alternative approach using the distal rectum. Case presentation: A 32-year-old woman presented with an anorectal malformation characterized by proximal vaginal agenesis and a rectovestibular fistula. Her symptoms became apparent during sexual activity, which was accompanied by fecal odor and menstrual blood mixing with stool. Initial workup revealed normal internal genitalia (uterus), with short vaginal defect and rectovaginal fistula. A two-stage surgery was performed: initial colostomy followed by posterior sagittal anorectoplasty (PSARP) and neovaginoplasty using the distal rectum. At the 3-month follow-up, the patient demonstrated functional and cosmetic recovery with no complications. Clinical discussion: Rectovestibular fistula with atretic vagina or complete vaginal absence being an uncommon condition constitutes a distinct spectrum of anorectal abnormality, which is always due to failure of the urorectal septum to develop. Previous reports show the use of the distal rectum for neovaginal reconstruction associated with the posterior sagittal approach. We successfully followed the same approach in our patient without resorting to abdominal mobilization of the bowel segment resection. This case supports the distal rectum-based neovaginoplasty as a viable alternative in resource-limited settings. Conclusion: Adult presentation of rectovestibular fistula with vaginal agenesis is rare. The use of the distal rectum for neovaginal reconstruction via PSARP is a feasible, low-risk option in resource-limited settings.