Repair Of Rectovaginal Fistula Research Articles

Surgical repair of rectovaginal fistula by combined transanal and transvaginal endoscopy: a case report

The common causes of rectovaginal fistula include obstetric trauma, local infection, and rectal surgery, while rectovaginal fistula following hemorrhoid surgery is extremely rare. Rectovaginal fistulae (RVF) rarely heal without intervention. Surgical treatment is usually performed, but the optimal surgical method remains controversial. The patient was a 37-year-old woman who was transferred to our hospital due to an unsuccessful repair of a rectovaginal fistula after hemorrhoid surgery in a local hospital. The next day after admission, she had prophylactic ileostomy, fecal diversion and combined treatment with cephalosporin antibiotic to create a clean postoperative area. However, there was still fecal outflow from the vagina, with no significant reduction in excretion compared to previous surgery. Digestive endoscopy confirmed a failure of the repair for rectovaginal fistula. Therefore, preventive ileostomy was continued to reduce the accumulation of bacteria in the fistula and control the inflammation. After 8 weeks, the endoscopic fistula inflammation disappeared, and the condition of endoscopic surgery was considered to be mature. Subsequently, a new surgical method combining transanal endoscopy and transvaginal endoscopy was performed. After 12 weeks of surgery, a follow-up endoscopic examination showed that the fistula had been repaired and healed. During the 1-year follow-up, no serious complication was encountered, no recurrence was found, and the repair effect was satisfactory. In conclusion, a new technique combining transanal endoscopy and transvaginal endoscopy can effectively be used for the surgical repair of rectovaginal fistula after a hemorrhoid operation.

Stapled transperineal rectovaginal fistula repair for low- and mid-level rectovaginal fistulas: A comparison study with rectal mucosal advancement flap repair

BackgroundAs an innovative treatment, stapled transperineal rectovaginal fistula repair (STR) for rectovaginal fistula (RVF) has demonstrated effectiveness in preliminary reports. This study aims to compare STR with rectal mucosal advancement flap repair (RAF), a widely utilized surgical procedure, for the surgical outcome of the low- and mid-level RVF. MethodsIn this retrospective cohort study, patients with low- and mid-level RVF who underwent STR or RAF were included from both the Sixth Affiliated Hospital of Sun Yat-sen University and Xi'an Daxing Hospital. Among the 99 total patients, 77 underwent STR and 22 underwent RAF. Patient demographics, operative data, and outcomes were collected and analyzed. Recurrence rate and associated risk factors were evaluated. ResultsThere were no statistically significant differences among patients in terms of clinical characteristics like age, BMI, aetiology, and fistula features. During the follow-up period of 20 months (interquartile range 3.0–41.8 months), a total of 28 patients relapsed, with a significantly lower recurrence rate in the STR group (20.8 %) than in the RAF group (54.6 %) (P = 0.005). In the multivariate Cox analysis, STR was an independent protective factor against recurrence (HR: 0.37, 95%CI: 0.17–0.79, P = 0.01). Logistic regression indicated that there was no statistically significant difference between these two procedures in terms of surgical complications (OR: 0.53, 95%CI: 0.19–1.48, P = 0.23). ConclusionFor low- and mid-level RVF, STR may be an alternative option for treatment modality that offers a lower recurrence rate, without observed disadvantage in terms of surgical complication rates.

Repair of radiation-induced rectovaginal fistula with rectal stricture by a combined Tuttle, Turnbull-Cutait and Singapore flap approach.

Radiation-induced rectovaginal fistula (RI-RVF) with associated rectal stricture represents a challenging problem in management. The aim of the present technical note is to describe a surgical technique aimed at minimizing disease recurrence by avoiding radiated tissue in the reconstruction: 1. Tuttle longitudinal incision of posterior vaginal wall with sharp excision of proximally located fistula; 2. Resection of strictured rectum via a combined transvaginal/laparotomy access, reconstruction with Turnbull-Cutait colon pull-through, and delayed handsewn coloanal anastomosis with loop ileostomy; 3. Bridge closure of the posterior vaginal wall by the interposition of a Singapore flap. This approach resulted in a favorable outcome at the 1-year follow-up in one patient with a medical history of gynecological carcinoma status after hystero-salpingo-oophorectomy followed by adjuvant radiation.

Rectovaginal Fistula Repair Following Vaginoplasty in Transgender Females: A Systematic Review of Surgical Techniques

Background: Rectovaginal fistula (RVF) remains a complex complication following gender-affirming vaginoplasty. This review aims to evaluate RVF repair techniques and outcomes following vaginoplasty. Methods: A systematic review was performed per PRISMA guidelines. Ovid MEDLINE, Ovid EMBASE, Cochrane, and Web of Science were queried for records pertaining to RVF repair following vaginoplasty. Study characteristics, operative details, and demographics were collected. Outcomes included RVF repair method, recurrence rate, and complications. Results: Among 282 screened citations, 17 articles representing 41 patients were included. Rectovaginal fistula repair methods identified included 4 conservative management approaches (n = 12 patients), primary closure with or without fistulectomy and ostomy (n = 22), 10 reconstructive surgical techniques (n = 18). The most common reconstructive techniques were V-Y full-thickness advancement with rectal flap (n = 5) and infragluteal fasciocutaneous flap (n = 4). Median time to recurrence was 6 months (interquartile range 7.5). Reported RVF repair complications included RVF recurrence (n = 5, 14.7%) and wound complication or dehiscence (n = 2, 5.88%). Three cases of RVF recurred after primary closure with or without fistulectomy and ostomy, while 2 cases of recurrence followed reconstruction. Conclusion: There remains a high level of variability in the approach to RVF repair following vaginoplasty. Reconstructive surgical techniques may be a more optimal solution without necessitating ostomies, but this decision must be considered in the context of RVF location, individual patient expectations, and clinical presentation.

Two Decadal Experiences in Managing Combined Obstetric Vesicovaginal and Rectovaginal Fistulas: A Study From Northern Indian Tertiary Hospital.

A retrospective study of 28 patients with obstetric combined vesicovaginal fistula (VVF) and rectovaginal fistula (RVF) treated at our centre throughout the last two decades (2002 to 2022) has been conducted. In 12 patients, a preoperative diverting colostomy was performed. Six patients had single-stage surgery (both VVF and RVF repairin the same operation) of which two cases required transabdominal repair and four required transvaginal repair. All single-stage repairs (n=6) were successful in curing urine and faecal incontinence.In 22 patients, VVF was corrected initially via the transvaginal method with Martius flap interposition, followed by RVF repair three months later. In 2/22 patients, there was a leak after RVF repair; therefore, proximal diverting colostomy was performed, and RVF repair was repeated after six months. All cases had effective VVF and RVF repairs, and both urine and faecal incontinence were completely cured. This study suggests the collaborative engagement of aurologist and a surgical gastroenterologist results in an advantageous outcome for the surgical treatment of these intricate obstetric fistulas.

Accurate anatomic repair of obstetric anal sphincter damage or rectovaginal fistula aided by prior ultrasonograghy: a cohort study.

A retrospective review of patients who underwent transvaginal surgical repair of RVF and ASD was undertaken. Patients were preoperatively assessed for pathology and incontinence degree. Anorectal ultrasonography was used to define ASD or RVF and the associated scar preoperatively. Repair of RVF or ASD entails total excision of the scar with accurate anatomical layers reconstruction of healthy tissues. There were 23 patients, 8 RVF with a mean (SD) age 29 (6.78) years and 17 ASD with a mean (SD) age 35.25 (15.90). Twenty followed obstetric trauma (6RVF, 14 ASD), 1 prior rectocoele repair (ASD), 2 rape (1RVF + 1 ASD) and 1 was idiopathic (RVF). All patients had 1 or more prior repairs except for idiopathic RVF. Operative technique entailed transvaginal complete excision of the fibrous scar and accurate anatomical reconstruction of healthy tissue layers. A colostomy was not routinely used. There were three significant postoperative complications: ASD breakdown from an infected haematoma; perianal abscess, later a sinus after drainage; and RVF repair dehiscence during early coitus. All patients had full continence after 8 months minimum follow-up. Complete excision of the fibrous scar and accurate anatomical tissue layers reconstruction of the obstetric RVF or ASD, aided by prior ultrasonography, yielded good results.

Gracilis Muscle Interposition: A Valuable Tool for the Treatment of Failed Repair of Post-partum Rectovaginal Fistulas-A Single-Center Experience.

Rectovaginal fistulas (RVFs) account for approximately 40% of anorectal complications from obstetrical trauma. Treatment can be challenging requiring multiple surgical repairs. Interposition of healthy transposed tissue (lotus or Martius flap or gracilis muscle) has been used for recurrent RVF. We aimed to review our experience with gracilis muscle interposition (GMI) for post-partum RVF. A retrospective analysis of patients who underwent GMI for post-partum RVF from February 1995 to December 2019 was undertaken. Patient demographics, number of prior treatments, comorbidities, tobacco use, postoperative complications, additional procedures, and outcome were assessed. Success was defined as absence of leakage from the repair site after stoma reversal. Six of 119 patients who underwent GMI did so for recurrent post-partum RVF. Median age was 34.2 (28-48) years. All patients had at least 1 previously failed procedure [median: 3 (1-7)] including endorectal advancement flap, fistulotomy, vaginoplasty, mesh interposition, and sphincteroplasty. All patients underwent fecal diversion prior to or at initial procedure. Success was achieved in 4/6 (66.7%) patients; 2 underwent further procedures (1 fistulotomy and 1 rectal flap advancement) for a final 100% success rate as all ileostomies were reversed. Morbidity was reported in 3 (50%) patients, including wound dehiscence, delayed rectoperineal fistula, and granuloma formation in one each, all managed without surgery. There was no morbidity related to stoma closure. Gracilis muscle interposition is a valuable tool for recurrent post-partum RVF. Our ultimate success rate in this very small series was 100% with a relatively low morbidity rate.

Treatment of Rectovaginal Fistula.

Rectovaginal fistula (RVF) is a challenging complication with unsatisfactory success and a significant burden for the patients. With insufficient clinical data due to the rare entity, the present state of treatments for RVFs was reviewed especially form the point of factors to determine management, classifications, principle of treatment, conservative and surgical treatments with outcomes. Size, fistula localization and etiology, type of fistula; "simple" or "complex," status of anal sphincter complex and surrounding tissue, presence or absence of inflammation, presence of diverting stoma, previous attempted repair and radiation therapy, patient's condition with co-morbidities, and surgeon's experience are important factors to determine the management of RVF. The inflammation should initially subside in cases with infection. Starting with conservative surgical options and interposing healthy tissue for complex or recurrent fistulas, invasive procedures will be performed if conservative treatment failed. Conservative treatment may be effective in RVFs with minimal symptoms and should be done for small RVFs for a 36 months usual period. Anal sphincter damage might need a repair of sphincter muscles along with RVF repair. Diverting stoma can initially be constructed in patients with severe symptoms and larger RVFs to relief the patient's pain. Simple fistula is usually indicated for local repair. Local repairs to transperineal and transabdominal approaches can be used for complex RVFs. Interposition of healthy, well-vascularized tissue can be required for more complex fistulas and abdominal procedures for high RVFs.

Thirteen-year audit of the management of anorectal fistulae in a tertiary colorectal unit

Persistent anorectal fistulae are referred for assessment in the Durban Metropolitan area to the colorectal unit at the tertiary hospital. This audit aimed to report the assessment and management of these fistulae to benchmark the outcomes from these approaches at a South African tertiary colorectal unit. Retrospective analysis of prospectively collected data of patients with anorectal fistulae over a 13-year period at a tertiary referral centre. Data analysed included demographics, clinical presentation, comorbidity, management and outcome. Study outcomes measures were healing time and secondary outcome measures were complications of surgery. One hundred and thirty-three patients (median age 44 and M:F ratio 2.8:1) with 206 fistulae were accrued. The initial assessment and diagnostic procedures included insertion of seton (126), fistulectomy (14), and fistulotomy (65). Definitive procedures included two-stage seton fistulotomy (43), ligation of the inter-sphincteric fistula tract (LIFT) procedure (39), modified Hanley procedure (17), and mucosal advancement flap (5). One patient had no surgery and nine did not undergo a definitive procedure. Additional procedures included anal sphincter reconstruction (2) and repair of rectovaginal fistula (2). Residual anal incontinence occurred in 13.5%. The failure rate was 6% and healing occurred in 94%. The median healing time was 8 months after the initial surgery and 4 months following the definitive procedure. The fistula healing rate overall was 94% and was associated with an incontinence rate of 13.5%.

Minimally invasive endoscopic repair of rectovaginal fistula.

BACKGROUNDSurgical techniques for repair of rectovaginal fistula (RVF) have been continually developed, but the ideal procedure remains unclear. Endoscopic repair is a novel and minimally invasive technique for RVF repair with increasing reporting. AIMTo review the current applications and preliminary outcomes of this technique for RVF repair, aiming to give surgeons an alternative in clinical practice. METHODSAvailable articles were searched according to the search strategy. And the sample size, fistula etiology, fistula type, endoscopic repair approaches, operative time and hospital stay, follow-up period, complication and life quality assessment were selected for recording and further analysis.RESULTSA total of 11 articles were eventually identified, involving 71 patients with RVFs who had undergone endoscopic repair. The principal causes of RVFs were surgery (n = 51, 71.8%), followed by obstetrics (n = 7, 9.8%), inflammatory bowel disease (n = 5, 7.0%), congenital (n = 3, 4.2%), trauma (n = 2, 2.8%), radiation (n = 1, 1.4%), and in two patients, the cause was unclear. Most fistulas were in a mid or low position. Several endoscopic repair methods were included, namely transanal endoscopic microsurgery, endoscopic clipping, and endoscopic stenting. Most patients underwent > 1-year follow-up, and the success rate was 40%-93%, and all cases reported successful closure. Few complications were mentioned, while postoperative quality of life assessment was only mentioned in one study. CONCLUSIONIn conclusion, endoscopic repair of RVF is novel, minimally invasive and promising with acceptable preliminary effectiveness. Given its unique advantages, endoscopic repair can be an alternative technique for surgeons.

Transvaginal approach for rectovaginal fistula: experience from a single institution

Transvaginal (TV) repair, featuring its feasibility, effectiveness, safety, and technically less demandingness, is one of the surgical approaches for management of rectovaginal fistula (RVF). However, there are limited numbers of publications available on the transvaginal approach for RVF repair. To this end, the purpose of this study is to evaluate the preliminary outcomes of the transvaginal approach performed by the team, and to further assess its feasibility, safety and effectiveness in the management of RVF. A retrospective analysis was conducted at a single institution. Patients with RVF who had undergone three transvaginal surgical techniques, i.e. transvaginal fistulectomy and stratified suture, transvaginal flip and ligation fistula tract and transvaginal fistula stapled closure were included. Besides, the demographics, operative data, postoperative complications and follow-up outcomes of the patients were collected prospectively. A total of 49 female patients (mean age, 35.76 ± 13.97years) underwent transvaginal approach, 42 of which were followed up with a median follow-up of 26months (range 3-82months), and 29 had closure of the fistula (successful closure rate of 59.1%). The successful closure rates were only significantly different between previous repair times (p = 0.031), and several minor complications including postoperative pain (n = 3), constipation (n = 1), and lower urinary tract infection (n = 1) were observed. Symptomatic improvement was reported in all patients with failed closure. Transvaginal approach for RVF repair is effective, safe, and feasible, and is therefore considered an alternative to transrectal advancement flap for low and mid-level traumatic RVF with normal sphincter function. With the advantage of better surgical access, transvaginal approach is recognized as the initial choice for the surgical repair of RVF.

Rectovaginal Fistula Management in Low-Resource Settings.

Rectovaginal fistula (RVF) is an abnormal connection between the rectum and vagina that affects women globally. In low- and middle-income countries (LMIC), RVF is most commonly due to obstetric complications such as prolonged labor or perineal tears, female genital mutilation and trauma such as sexual violence or iatrogenic surgical injuries. Women affected by this condition suffer from debilitating physical symptoms, social isolation, economic disempowerment, psychological trauma, low self-esteem, and loss of role fulfillment. Lack of accessible, high-quality, and effective healthcare is a major barrier to timely and safe obstetric care and to care for subsequent complications such as RVF. Additionally, social, cultural, financial, and systemic barriers put women at risk of acquiring fistula and contribute to delays in seeking and receiving care. Literature evaluating RVF repair in those able to access care offers limited information about management and outcomes. It is difficult to ascertain which surgical techniques are used. To reduce the burden of this often-preventable disease, appropriate investment in healthcare infrastructure to strengthen maternal care in LMICs is paramount. Furthermore, more standardized reporting of severity and treatment approach along with outcome data are critical to improving the quality of care for patients impacted by RVF.

Surgical treatment of rectovaginal fistula—predictors of outcome and effects on quality of life

PurposeTo determine the results after rectovaginal fistula (RVF) repair and find predictors of outcome. Primary objective was fistula healing. Secondary outcomes were morbidity and patient health-related quality of life (HRQoL).MethodAn observational study of 55 women who underwent RVF repair including both local procedures and tissue transposition 2003–2018 was performed. Baseline patient and fistula characteristics were registered, combined with a prospective HRQoL follow-up and a general questionnaire describing fistula symptoms.ResultsHealing rate after index surgery was 25.5% (n = 14) but the final healing rate was 67.3% (n = 37). Comparing the etiologies, traumatic fistulas (iatrogenic and obstetric) had the highest healing rates after index surgery (n = 11, 45.9%) and after repeated operations at final follow-up (n = 22, 91.7%) compared with fistulas of inflammatory fistulas (Crohn’s disease, cryptoglandular infection, and anastomotic leakage) that had inferior healing rates after both index surgery (n = 7, 7.1%) and at final follow-up (n = 13, 46.4%). Fistulas of the category others (radiation damage and unknown etiology) included a small amount of patients with intermediate results at both index surgery (n = 1, 33.3%) and healing rate at last follow-up (n = 2, 66.7%). The differences were statistically significant for both index surgery (p = 0.004) and at final follow-up (p = 0.001). Unhealed patients scored lower than both healed patients and the normal population in 6/8 Rand-36 domains, but the differences were not statistically significant.ConclusionsMost traumatic rectovaginal fistulas closed after repeated surgery whereas inflammatory fistulas had a poor prognosis. Low healing rates after local repairs suggest that tissue transfer might be indicated more early in the treatment process. Unhealed fistulas were associated with reduced quality of life.Trial registration Clinicaltrials.gov No. NCT05006586.

Rectovaginal Fistula Repair with a Vascularized Gracilis Muscle Interposition Flap

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Buccal Mucosal Grafts as a Novel Treatment for the Repair of Rectovaginal Fistulas: Protocol for an Upcoming Prospective Single-Surgeon Case Series.

BackgroundRectovaginal fistulas (RVFs) are abnormal communications between the rectum/anus and the vagina. They are most frequently formed a result of obstetric injury and have deleterious effects on patients’ quality of life. Despite several treatment modalities, RVFs remain difficult problems to manage, and many patients fail multiple attempts at surgical repair. Buccal mucosal grafts (BMGs) may be a solution to this problem. A BMG is an oral mucosal tissue harvested from the inner cheek. There are 2 case reports that describe the successful use of BMGs in the repair of RVFs.ObjectiveOur objective is to validate these findings with a prospective case series while also addressing the key issues of indication, technical details, procedure safety, and short-term outcomes.MethodsA prospective single-surgeon case series will be undertaken at a university-affiliated academic tertiary care hospital in Calgary, Alberta (Canada). The estimated recruitment is between 3 and 5 patients. Patients will undergo surgical repair of their RVFs with an autologous BMG. Data on patient characteristics, fistula characteristics, and surgical variables will be collected and analyzed prospectively. The primary outcome is fistula closure. This study has been approved by the Conjoint Health Research Ethics Board at the University of Calgary (REB20-1123).ResultsTwo previous case reports have described the successful use of BMGs in the repair of RVFs. We have received ethics approval to attempt to validate these findings through a prospective case series.ConclusionsRVFs cause significant patient morbidity and are difficult problems to manage. Bolstered by the successful use of BMGs in urologic surgery and the previously published case reports demonstrating success in RVFs, we believe that BMGs may be a solution to RVFs.International Registered Report Identifier (IRRID)PRR1-10.2196/31003

Robotic-assisted vesicovaginal fistula repair using a vaginal cuff flap

Vesicovaginal fistula (VVF) is an abnormal communication between the bladder and the vagina. Complex fistulae include those after failed repair attempts, radiotherapy, measuring ≥ 2 cm, located in the trigone, or with concomitant ureteric strictures or fistulae. We aimed to describe a technique for the robotic repair of a complex VVF using a vaginal cuff flap. A 56-year-old woman with a history of ovarian debulking surgery and radiotherapy underwent repair for VVF and rectovaginal fistula. In lithotomy, cystoscopy was performed for fistulous tract cannulation. Port placement, extensive adhesiolysis, and robot docking followed. The vaginal apex was dissected, the VVF excised, and the bladder closed. The rectum was separated from the posterior vaginal wall, the rectovaginal fistula excised, and the rectum closed. A vaginal cuff flap was harvested and interposed between the bladder and the vagina. Operative time was 9 h, estimated blood loss was 300 cc, and no intraoperative complications occurred. The patient was discharged on postoperative day 8. Further management included 37 sessions in a hyperbaric chamber and a transvesical endoluminal bladder closure 10 months after the initial surgery. Follow-up at 30 months shows no fistula recurrence. Vaginal cuff flaps represent a feasible interposition tissue in patients with hysterectomy for managing complex VVF in the case of omentum unavailability.

Laparoscopic omental flap for rectovaginal fistula after low anterior resection

Abstract Introduction: Nearly 1.8% to 9.9% of patients suffer from a rectovaginal fistula after a low anterior resection. The treatment and management of rectovaginal fistulas is challenging for surgeons. Here, we report a case of rectovaginal fistula after low anterior resection that was successfully treated with laparoscopic omental flap surgery. Patient Concerns: An 89-year-old woman underwent laparoscopic low anterior resection for stage IIA rectal adenocarcinoma. The patient noticed fecal discharge from her vagina 6 days postoperatively. Diagnosis: Enema examination results using a contrast agent showed a 1 cm rectovaginal fistula located 1 cm proximal to the anastomotic stapler line. Interventions: We performed laparoscopic rectovaginal fistula repair using an omental flap and laparoscopic transverse colostomy 12 days postoperatively. The omentum was placed between the vaginal and rectal walls and secured with sutures. Outcomes: Oral food intake was resumed 2 days postoperatively, and there were no signs of recurrence of the rectovaginal fistula. The patient underwent a procedure to close the colostomy 36 days after the second surgery. Conclusion: Laparoscopic surgery is helpful in achieving good access during surgery, especially in narrow areas, such as the pelvis. It is essential to use a flap in good condition to treat a rectovaginal fistula. Omentum is an ideal flap with good blood flow that exerts no tension on the tissue. Hence, laparoscopic omental flap is a feasible treatment option for rectovaginal fistulas.

Gracilis Muscle Interposition: A Valuable Tool for the Treatment of Failed Rectovaginal Fistula Repair Due to Obstetric Injury: Single Center Experience

Gracilis Muscle Interposition: A Valuable Tool for the Treatment of Failed Rectovaginal Fistula Repair Due to Obstetric Injury: Single Center Experience

A retrospective case series on transvaginal repair of rectovaginal fistula performed by a urogynaecology operative team in Australia.

Rectovaginal fistula (RVF) is an abnormal epithelialised connection between the rectum and vagina. It is a common condition in limited resource settings and is caused almost exclusively by obstetric injury. In contrast, RVF is uncommonly seen in high resource settings. This study aims to review the aetiology and effectiveness of RVF management in the high resource setting, identifying predictors for repair success and long-term outcomes. A retrospective case series study of patients who underwent transvaginal RVF repairs at two secondary healthcare facilities over a 14-year period by one operative group. A total of 41 patients underwent 46 surgical repairs. All patients presented with flatal and/or faecal incontinence and aetiology was identifiable in 78.0% (n=32). Obstetric cause was implicated in 26.8% (n=11) and other causes include 26.8% (n=11) from vaginal and abdominal surgery, 14.6% (n=6) from perianal abscess, 7.32% (n=3) as complications of Crohn's disease and 2.44% (n=1) as a complication of a cube pessary. Fistula was cured in 38 of 41 cases (92.7%) with a primary repair closure rate of 80.5% (n=33). Post-operative symptoms were limited to flatal incontinence in 4.88% (n=2), faecal incontinence in 2.44% (n=1), and persistent perineal pain in 7.32% (n=3). The success of the surgical repair was not significantly impacted by fistula size, aetiology, presence of a stoma for diversion, history of prior repair, duration since RVF formation or repair technique. This review identifies aetiology for RVF in the high resource setting and highlights the role of earlier surgical repair to minimise patient morbidity with good success in closure and reduction of post-operative symptoms.

What is the best method of rectovaginal fistula repair? A 25-year single-center experience.

The surgical treatment of rectovaginal fistula (RVF) remains challenging and there is a lack of data to demonstrate the best, single procedure. The aim of this study was to assess the results of different surgical operations for rectovaginal fistula. Patients with RVF who underwent surgical repair between 1992 and 2017 at a single, tertiary care center were included. Twenty different procedures were performed including: primary closure, closure with sphincter repair, flap repairs, plug/fibrin/mesh repair, examination under anesthesia (EUA) ± seton placement, abdominal resections with and without diversion and ileostomy takedown, gracilis muscle transposition, fistulotomy/ligation of intersphincteric fistula tract. All patients with RVF due to diverticulitis and patients without complete data from paper charting were excluded. Success was defined based on the absence of symptoms related to RVF and absence of diverting stoma at 6months. One hundred twenty-four women were analyzed. The median age was 45 (range 18-84) years. Median follow-up time from the last procedure was 6months (range 0-203months). The total number of patients considered successfully treated at the end of their treatment was 91 (91/124, 73.4%). When considering all procedures (n = 255), the success rate for flap procedures was 57.9% (22/38), followed by abdominal resections with and without proximal diversion and ileostomy takedown (16/29, 55.2%) and primary closure with sphincter repair (17/32, 53.1%) while fistula plug, and fibrin glue had among the lowest success rates (4/22, 18.2%). The highest success rate was observed among patients whose RVF etiology was due to malignancy (11/16, 68.8%) followed by unknown (8/14, 57%) and iatrogenic (21/48, 43.8%) causes. Local procedures such as mucosal flap or primary closure and sphincteroplasty are associated with a high success rate should be considered in patients with low-lying, simple RVF. Abdominal resections with and without proximal diversions and ileostomy takedown have a relatively high success rate in selected patients. The low success rate of fibrin glue and fistula plugs demonstrates their low efficacy in RVF; thus, these procedures should be avoided in the treatment algorithm.