A case of delayed fistula after Total Prolift™ procedure  for recurrent anterior vaginal wall prolapse and vault prolapse is presented.

A 50-year-old woman, smoker, with Latent Autoimmune Diabetis with bad control of the disease, Arterial Hypertension, a history of a vaginal hysterectomy and an anterior colporrhaphy for uterine prolapse and cystocele in 2009, a Total Prolift™(monofilament polypropylene mesh) mesh for recurrent anterior vaginal wall prolapse and vaginal vault prolapse in 2010 (complicated with a self-limiting hemoperitoneum) presented with a mesh extrusion of 3cm per 3cm in the area of the vaginal vault in 2014. A surgical correction of the extrusion was offered to the patient but the patient refused it. The patient did not come to the subsequent visits. In 2015, the patient presented with a 5x4 cm nodule in the right buttock compatible with an abscess. At the same time, the patient presented purulent drainage in her vagina. Oral Antibiotic treatment was given to the patient and the patient improved. The patient presented several similar episodes, in the last one she presented purulent drainage through two holes in her right buttock. One hole was located at the upper level of the right buttock and the other at the right parasacral level (Figure 1). At the instillation of hydrogen peroxide through a hole, the water came out through the other hole and also through vagina.
With a suspiction of a vaginal-gluteal fistula a pelvic MRI was performed. The MRI showed a fistula arising from the right side of the vaginal vault with a 5cm path towards the rear, up and to the right with a thickness of 14mm, up to the gluteal musculature where it divided into two paths:
-	The first about 7.5cm path that followed up, back and rotated medial until it ended at cutaneous level, to the right of the middle line in the right buttock. 
-	The second path followed a medial and downward direction of about 10 cm in length and had cutaneous orifici on the lower portion of the right buttock, to the right of midline. 

An endoanal ultrasound was perfomed and no internal or external fistulae appeared.

A fistulectomy was perfomed with collaboration of urogynecologists and traumatologists. 
First step: Excision in spindle of two fistulas in the right gluteal region with the patient in lateral decubitus was performed. Dissection was performed and it was detected that both fistulas were communicated between them. Through one of them partial removal of the mesh was achieved (Figure 2) Two samples were taken for culture. Abundant washing was done. A drainage was left. Subcutaneous suture. The skin was closed with staples.
Second step: vaginal time. Patient in dorsal litotomy position. 
Big extrusion of the Prolift mesh in vaginal vault and a small extrusion in posterior vaginal wall were found. Purulent drainage through extruded mesh in vaginal vault was observed. Resection of the extruded vault mesh and expansion of the resection laterally was performed. Washing with iodine and serum was done. Resection of posterior mesh extrusion was performed. Vault incision was left opened. A rectal examination was perfomed at the end of the surgery to confirm rectal integrity.

Mesh complications can appear several years after their placement. Some complications require specialized care. The basic diseases can favor the appearance of complications.

Int Urogynecol J. 2013 Nov;24(11):1859-72. doi: 10.1007/s00192-013-2177-9. Complications of pelvic organ prolapse surgery and methods of prevention. de Tayrac R1, Sentilhes L.
Eur J Obstet Gynecol Reprod Biol. 2012 Dec;165(2):170-80. doi: 10.1016/j.ejogrb.2012.09.001. Epub 2012 Sep 19. Prevention of complications related to the use of prosthetic meshes in prolapse surgery: guidelines for clinical practice. Deffieux X1, Letouzey V, Savary D, Sentilhes L, Agostini A, Mares P, Pierre F; French College of Obstetrics and Gynecology (CNGOF).