Transperineal approach technique for the treatment of slow-flow perirectal vascular malformations

Perirectal vascular malformations are uncommon and difficult lesions due to their deep location and proximity to vital pelvic structures. Traditional treatments include endoscopic, percutaneous, or surgical methods, each with potential risks. We aim to describe a novel, minimally invasive transperineal approach technique for treating perirectal venous and lymphatic malformations using combined polidocanol and bleomycin sclerotherapy.

Three patients with perirectal vascular malformations were treated using a transrectal digital-guided (finger) approach under fluoroscopic control. After lesion mapping with ionic or non-ionic contrast, sclerotherapy was performed using polidocanol-based foam combined with bleomycin.

All procedures were technically successful. The approach allowed accurate localization, safe puncture, and effective sclerosis of the lesions while reducing procedural trauma. Postoperative pain was mild and self-limited. No cases of systemic toxicity, deep venous thrombosis, or tissue necrosis were observed during follow-up.

The transperineal approach provides a safe and effective alternative for treating perirectal vascular malformations, offering excellent anatomic control and reduced morbidity. Combined polidocanol-bleomycin sclerotherapy appears to be a feasible and well-tolerated therapeutic option; however, larger studies are needed to confirm its efficacy and long-term outcomes.Clinical ImpactThe transperineal approach for the management of slow-flow vascular malformations represents a practical, safe, and reproducible therapeutic option that provides minimally invasive access to complex perirectal lesions. By eliminating the need for endoscopic instruments or major surgical procedures, it reduces both procedural risks and associated costs. Its technical simplicity and minimal equipment requirements facilitate its implementation in most vascular centers, broadening access to specialized care across various clinical settings.