Management of a Complex Y-Shaped Anal Fistula with Periscrotal Extension: The Role of FiLaC in a Sphincter-Preserving Strategy

Abstract: Branching complex anal fistulas with anterior or periscrotal extension are uncommon and represent a therapeutic challenge, as eradication of sepsis must be balanced against preservation of anal continence. A 34-year-old man with no previous proctologic history presented with chronic perineal suppuration evolving over several months, associated with intermittent local pain. Clinical examination suggested a complex Y-shaped anal fistula with a single internal opening, multiple external openings, and a long anterior tract extending toward the periscrotal region, associated with a subcutaneous cavity. No clinical features suggestive of inflammatory bowel disease were identified. Operative exploration confirmed the fistulous anatomy. Fistulectomy of accessible tract segments was performed, followed by placement of two draining setons in order to control sepsis while preserving the sphincter complex. Concomitant hemorrhoidal disease, considered incidental, was treated separately during the same surgical session. Early postoperative outcome was favorable. Complex Y-shaped anal fistula with periscrotal extension is a rare anatomical presentation. A staged therapeutic strategy based on initial sepsis control with draining setons followed by definitive sphincter-preserving treatment may optimize outcomes while minimizing the risk of continence impairment. In this setting, FiLaC may represent a valuable option among definitive treatment modalities.