Treatment Of Rectovaginal Fistula Research Articles

Chinese experts consensus on diagnosis and treatment of rectovaginal fistula (2022 edition)

Rectovaginal fistula (RVF) is an abnormal connection between the rectum and the vagina. At present, the principle method for RVF is surgery. With a variety of surgical methods, clinicians still lack a generally recognized consensus on RVF. Therefore, based on latest evidence from literature and expert experience, the Clinical Guidelines Committee of Chinese Medical Doctor Association Anorectal Branch organized domestic experts in anorectal surgery and gynecology to discuss the etiology, classification, diagnosis, treatment and special types of rectovaginal fistula of RVF, through questionnaires and expert seminars. "Chinese experts consensus on the diagnosis and treatment of rectovaginal fistula (2022 edition)" was produced in order to deepen the understanding of RVF, and to provide a standardized treatment for RVF in order to reduce the failure rate of surgery.

English

Rectovaginal fistulas (RVF) result from an abnormal epithelial connection between the vagina and the rectum, allowing the intestinal contents to pass through the vagina.1 Patients may clinically present with vaginal faeces or gas discharge in addition to inflammation in the pelvic cavity, which may lead to severe infection and poor quality of life.2 RVF is seen in women who previously received treatment for a malignant disease in the pelvic region. The malignancies in the pelvic area are often treated with radiotherapy. This treatment results in tissue damage and poor healing.3 Management of postoperative RVF is difficult and the results are often unsatisfactory. Currently there is no widely accepted and standardized treatment for RVF.3, 4 In the treatment of RVF, various surgical flaps (endorectal or vaginal), vascular tissue flaps (Martius, gracilis), grafts or biomaterials have been used.3,5,6 This case shows the first results using the Amplatzer™ Septal Occluder for the closure of rectovaginal fistula.

83 Dehydrated human amniotic membrane and amniotic fluid for the treatment of rectovaginal fistulas

The presence of a rectovaginal fistula (RVF) can be devastating to patients thus greatly affecting their quality of life. The most common etiologies of RVF are those resulting from obstetric complications, pelvic radiation, malignancy, infection, and postoperative complications. The treatment of RVF is mainly surgical; however, current techniques still have a high rate of recurrence. Our objective is to present a novel surgical technique with the use of a dehydrated amniotic membrane (VendajeTM) and an amniotic suspension allograft (RheoTM) in repair of rectovaginal fistula. Two cases of chronic rectovaginal fistula were seen in the urogynecology office. Informed consent was obtained to proceed with surgical repair using the dehydrated amniotic membrane and amniotic suspension allograft. Under general anesthesia, the RVF fistula repair was done by first using a #5 silk suture that was threaded back and forth in the fistula tract to de-epithelialize the tract and uncover healthy tissue (Figure 1). The rectal side of the fistula tract was closed with 3-0 vicryl interrupted sutures. The amniotic membrane was soaked in 1 mL of the amniotic suspension before being placed into the fistula tract from the vaginal side. The vaginal side of the tract was reapproximated with 3-0 vicryl interrupted sutures (Figure 2). Finally, the remainder of the amniotic suspension was injected into the tract. The patients were also advised to use estrace vaginal cream to promote wound healing and increase blood supply to the surgical site. One case of complete resolution (5 mm to closure) of rectovaginal fistula and one case of 90% improvement (1cm to 1mm) of fistula is presented utilizing a novel therapeutic approach with the amniotic membrane pre-soaked in an amniotic suspension allograft followed by injection of remaining allograft into the fistula tract. This novel application of dehydrated human amniotic membrane allograft and amniotic suspension allograft is an effective therapy for chronic rectovaginal fistula. This procedure also highlights the importance of the complexity of the fistula and health of the supporting tissue prior to fistula repair seen in the case with 70% improvement.

Botulinum Toxin Injection for the Treatment of the Recurrent Rectovaginal Fistulas in Combination with Surgical Repair

Rectovaginal fistula is abnormal connections between the vagina and rectum. Via this connection, the passages of flatus or stool from rectum to vagina occur. Patient history and physical examination are usually enough to make diagnosis of fistula. Although there are so many defined surgical options including sphincteroplasty, advanced flap, muscle interposition, fibrin glue, plugs, and closure of fistulas remain a challenging condition with the high rate failure of surgical repair In this study, we aim to report the results of a new treatment approach with the injection of botulinum toxin into lateral internal sphincter on the management of rectovaginal fistula in conjunction with the surgical repair. Between 2013 and 2019, 8 patients with recurrent rectovaginal fistula underwent 10 surgical repairs in conjunction with 100 units botulinum toxin injection. Results of these patients were analyzed. We have treated 8 patients with recurrent rectovaginal fistula. The etiology of fistula in our patients included obstetrical trauna (3 patients), radiotherapy and rectal surgery (2 patients), vaginal reconstruction (2 patients) and Crohn’s disease (1 patient). The median number of their previous operations was 1.5 (range, 1–3). The sizes of fistulas range from 0.5 × 1 to 2 × 3 cm. In our surgical intervention, at the end, all of them were closed (100%) successfully. Botulinum toxin injection into lateral internal sphincter can be used successfully in combination with surgical intervention for the treatment of the rectovaginal fistulas.

Effect of diverting stoma for rectovaginal fistula: A protocol of systematic review and meta-analysis.

Background:Rectovaginal fistula (RVF) is a pathologic channel between the anterior wall of the rectum and the posterior wall of the vagina, is rare, and the majority is of traumatic origin. The most common causes are obstetric trauma, local infection, rectal surgery or caused by chronic inflammatory bowel disease. Once the disease will seriously affect the patient's quality of life, and generally not self-healing, most require surgical intervention. At present, diverting stoma is mainly used in patients with severe RVF or complicated RVF or patients with Crohn disease. Due to the lack of large sample, linical studies, its clinical effectiveness is still controversial. The purpose of this systematic review is to evaluate the efficacy of diverting stoma in the treatment of diverting stoma.Methods:EMBASE, PubMed, the Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Wanfang Database, Chinese Biomedical Literature Database (CBM), and Chinese VIP Information will be searched systematically by 2 reviewers from the inception until October 2020. The original study that randomized controlled trials (RCTs), clinical controlled trials (CCTs), nonrandomized control trials (NCTs), and retrospective trials (RTs) of diverting stoma for RVF will be selected. In addition, similar searches will be conducted for the reference lists, researches in progress, and the citation lists of identified publications. Study selection, data extraction, and assessment of the quality will be performed independently by 2 reviewers who have been trained prior to data extraction. A meta-analysis will be conduct if the quantity and quality of the original studies included are satisfactory; otherwise, a descriptive analysis will be conducted. Review Manager 5.4 software (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark) will be using for data synthesis and assessment the risk of bias according by Cochrane Handbook.Result:This study will provide a comprehensive review of current evidence for the treatment of diverting stoma on RVF.Conclusion:The conclusion of this study will provide a judging basis that whether the treatment of RVF with diverting stoma is effective.Inplasy registration number:INPLASY2020090070.

Allogeneic expanded adipose-derived stem cells in the treatment of rectovaginal fistulas in Crohn's disease.

AimCrohn's disease (CD)‐related rectovaginal fistulas (RVFs) are rare, challenging to treat and associated with a high morbidity. Due to a significant lack of data, we aimed to analyse the safety and feasibility of allogeneic adipose‐derived stem cells (ASCs) in the treatment of CD‐related RVF.MethodFour consecutive patients with CD‐related RVF underwent treatment with expanded allogeneic ASCs extracted from a healthy donor in a tertiary referral centre in 2019. None of the patients had an intestinal diversion at the time of the treatment. Follow‐up was performed 6 months postoperatively.ResultsThe median operation time was 45 min with a median hospital stay of 3 days. No intra‐operative complications occurred. Three patients (75%) developed recurrent RVF after a median follow‐up of 19 days. Two patients required surgical treatment including loose seton drainage due to discharge and pain. One patient developed recurrence of symptoms after 10 days, but refused further surgical therapy. Only one patient (25%) showed healing of the RVF, with re‐epithelialization of both the vaginal and rectal opening and absence of clinical symptoms.ConclusionExpanded allogeneic ASC therapy represents a novel safe treatment option for CD‐associated RVF. Although efficacy appears limited, further controlled studies are required to draw robust conclusions.

Minimally invasive treatment of mid-low rectovaginal fistula: a transanal endoscopic surgery study.

Treatment of rectovaginal fistulas (RVFs) is extremely difficult. No standard surgical procedure is accepted worldwide. The aim of this article was to evaluate a minimally invasive procedure for the repair of mid-low rectovaginal fistula. This is a retrospective review of 17 patients who underwent minimally invasive surgery for the repair of mid-low rectovaginal fistulas (located in the lower or middle one-third of the vaginal wall) at our center between August 2016 and October 2018. The anal approach was adopted for 12 patients: 6 patients were treated directly by rectal mucosal advancement flap (RMAF) with transanal endoscopic surgery (TES), while the other 6 patients underwent initial TES exploration followed by RMAF procedure under direct vision. The vaginal approach was adopted for 5 patients: 3 patients were treated under TES directly and the other 2 were treated under direct vision after initial TES exploration. A total of 9 (52.94%) patients received diverting ileostomy-5 anal approach patients and 4 vaginal approach patients. Median age of the patients was 46years (range 10-76years), and median BMI was 21.9 (range 17.9-28.1). Median operative time was 75min (range 60-120min), and median duration of postoperative hospital stay was 8days (range 6-15days). Recurrence was seen in 3/12 anal approach patients vs. 0/5 vaginal approach patients. Both the median preoperative and the median postoperative Wexner score were 0 (range 0-2). The median follow-up time was 8months (range 2-24). No severe complications occurred in any patient. The TES procedure for the treatment of mid-low rectovaginal fistulas avoids any incision of the abdomen and perineal area and appears to be a safe and feasible procedure. This minimally invasive technique is still evolving and is likely to gain wide acceptance in the near future.

2048 Colo -Anal Anastomosis: A Novel Idea for Treatment of Re-Re-Recurrent Rectovaginal Fistula

Video Objective Treatment of rectovaginal fistulas was always difficult; treating post radiation recurrent rectovaginal fistulas was challenging; Colo-Anal Anastomosis is a novel way of treating such fistulas. Setting 49yr/Female/P1L1 had undergone Total Abdominal Hysterectomy for AUB-E; was diagnosed with adenocarcinoma of endometrium stage II. Patient underwent BPLND + BSO 3 weeks later and then took 25# radiation for same. Patient developed radiation proctitis and Rectovaginal Fistula following Radiation Therapy. A diversion colostomy was done for same. Patients complaints persisted. Patient then underwent RVF closure with omental flap interposition. Despite the omental flap a distal loopogram was suggestive of leak of dye. Interventions Decision was taken to do a Laparoscopy with Colo Anal Anastomosis. Expected challenges were dense bowel adhesions; deficient anterior rectal wall; Non healing tissue. On Laparoscopy small bowel adhesiolysis was done. Colon was completely mobilized upto splenic flexure so as to obtain a tension free repair. Rectum transected proximal to fistula site. A tunnel was created in the distal rectum. Rectal Mucosa was excised so as to avoid mucus passage. Mobilized bowel was then pulled out through the tunnel. Colon was anastomsed to anal canal perineally by simple interrupted sutures. As anal sphincters were not dissected patient's anal tone was well maintained. Rectal drain was placed. Patient was gradually started on full diet by day 3; rectal drain was removed on day3 post op. Dye study done postoperatively showed no leak of dye. Conclusion Colo Anal Anastomosis is a unique way of treating fistulas not responding to routine RVF repair procedures.

Surgical Repair of Rectovaginal Fistula Using the Modified Martius Procedure: A Step-by-Step Guide

Study ObjectiveTo demonstrate the surgical repair of a rectovaginal fistula (RVF) using the modified Martius procedure. DesignA step-by-step presentation of the procedure using video (Canadian Task Force classification III). SettingRVF is abnormal epithelialized connections between the vagina and rectum. Causes of RVF include obstetric trauma, Crohn disease, pelvic irradiation, and postsurgical complications. Many surgical interventions have been developed, from the laparoscopic technique to muscle transposition and even rectal resection. However, the treatment of RVF is a great challenge to gynecologic surgeons because the incidence of RVF is low and there is no high evidence for the best surgical approach to this disease. When RVF is persistent or recurrent, the surrounding tissue is always scarred or damaged, so the interposition of a healthy and well-perfused tissue is an appropriate approach to fistula management. The modified Martius procedure using adipose tissue from the labia major places well-vascularized pedicle in the place of the RVF. Limited studies involving the procedure present favorable successful rates. PatientConsent was obtained from the patient. The study was approved by the local ethics committee. InterventionThe surgical repair of rectovaginal fistula by the modified Martius procedure is described as follows: The patient is placed in the high lithotomy position. A temporary transurethral urinary catheter is placed preoperatively to keep the operative site clean. The rectovaginal fistula is identified by a fistula probe. A 4-cm incision is made vertically over the left labium majus from the level of the mons pubis to the bottom of the labium to harvest pedicle. It is imperative to ensure adequate length on the flap before transection. Blood supply to the fat-muscle flap is provided superiorly by the external pudendal artery, posteriorly by the internal posterior and laterally by the obturator artery. The fat-muscle flap is dissected in a lateral-to-medial direction and divided in the upper section by two clamps, preserving its posterior aspect intact to maintain its blood supply. After that the fistula is circumcised with a scalpel through the vaginal wall with a margin of healthy tissue. During the process, the rectovaginal septum is opened and wide mobilized so that a multilayer closure can be performed without any tension. Then a subcutaneous tunnel is made from the labium majus to the fistula with a forcep. It is also important to make the tunnel wide enough to easily accommodate the flap. The fat-muscle flap is pulled through the tunnel gently, ensuring proper orientation without kinking the blood supply. The rectal mucosa is sutured in one layer with 3-0 Vicryl in interrupted fashion. The flap is then sutured down to the rectal wall with four single sutures in interrupted fashion. So the rectal and vaginal walls are separated with a healthy, well-vascularized pedicle. In addition, the flap fills in the dead space and enhances granulation tissue. The vaginal mucosa is then closed over the pedicle with 1-0 Vicryl in interrupted suture without tension. The labial incision is closed in layers with absorbable suture. Neither incision is drained. Measurements and Main ResultsIn this video, we describe the modified Martius procedure for the management of RVF. We present a 26-year-old woman who suffered from RVF caused by obstetric trauma. She complained of passing flatus and feces through the vagina 1 week after vaginal delivery. Clinical examination performed in the local hospital confirmed RVF 1 cm in diameter located in the lower third of the vagina. The fistula was present for about 6 months, which brought psychosocial dysfunction to the patient. She was transferred to our clinic. After examination, the anal sphincter was intact. After mechanical bowel preparation with polyethylene glycol solution, the patient was presented for surgery. The operating time was about 40 minutes. No recurrence or complications were observed at the 4-month follow-up. A protective ileostomy or colostomy was avoided. The patient reestablished intestinal continuity. The functional and cosmetic results were excellent with high patient satisfaction and greatly improved quality of life. ConclusionThe Martius flap is easy to harvest with minimal external disfigurement and a minimal recovery time. The modified Martius procedure is a feasible adjuvant technique for RVF with excellent postoperative outcomes.

Treatment of rectovaginal fistula with gracilis muscle flap transposition: long-term follow-up.

Rectovaginal fistulas are difficult to treat completely, especially when patients present with a history of multiple surgeries and radiation therapy. We aimed to evaluate the efficacy of gracilis muscle flap transposition to treat rectovaginal fistula. We performed a retrospective chart review of all gracilis muscle transposition cases and other procedures between January 2009 and July 2016. Total 53 cases were reviewed. A total of 11 patients underwent gracilis muscle flap transposition for rectovaginal fistula repair, with 8 patients showing good results without recurrence (total success rate, 72.7%). Comparison of this patient group with patients who had undergone other surgical procedures for rectovaginal fistula repair showed that those who received a gracilis transposition flap had significantly higher average number of previous surgeries (2.18±1.17 vs. 1.1±1.25) and had previously undergone radiotherapy at a significantly higher rate (63.6 vs. 26.2%). Furthermore, none of our patients complained of donor site discomfort. Based on these results, we recommend using the gracilis muscle flap for rectovaginal fistula repair in cases where there is a history of radiotherapy and had surgical failure more than twice.

Treatment of rectovaginal fistula after colorectal resection with endoscopic stenting: long-term results.

To treat patients with rectovaginal fistula after anterior resection for cancer using self-expanding metal stents. Ten patients of mean age of 56.3years with rectovaginal fistula after colorectal resection for cancer were treated with endoscopic placement of a self-expanding metal stent. In three patients a diverting proximal stoma had been performed elsewhere. The rectal opening of the fistula was located from 3 to 10cm from the anal verge (mean 6cm). All patients had preoperative radiotherapy. In seven patients the stent was placed as the initial treatment while three referred patients had had multiple failed operations. There were no complications after the procedure. At a mean follow-up of 24months the rectovaginal fistula has healed without major faecal incontinence in eight patients. In the remaining two the fistula has reduced significantly in size to allow a successful flap transposition. Endoscopic placement of a self-expanding metal stent is a valid adjunct to treat patients with rectovaginal fistula after colorectal resection for cancer.

Research progress of the treatment of rectovaginal fistulas

Treatment of rectovaginal fistula (RVF) is extremely difficult. Successful performing operation to treat RVF is a major challenge, because recurrence has remained common. RVF has significant negative influence on the patient's quality of life and causes social embarrassment. Up to now, no standard surgical technique is accepted worldwide, no ideal treatment option is suitable for all the patients, and no recommendation of clinical treatment guideline of RVF is available. English literatures were reviewed in this article, from the causes of rectovaginal fistula, classification, diagnosis, surgical methods, surgical approach, minimally invasive technology application, perioperative management and the cause of operation failure aspects were reviewed in detail.

Surgical Approach for Repair of Rectovaginal Fistula by Modified Martius Flap

Rectovaginal fistulas (RVF) are rare but represent a challenge for both patients and surgeons. The most common cause of RVF is obstetric trauma, and treatment is based on fistula classification and localization of the fistula in relation to the vagina and rectum. Conventional therapy frequently fails, making surgery the most viable approach for fistula repair. One surgical procedure which offers adequate repair of lower and middle rectovaginal fistulas consists of interposition of a bulbocavernosus fat flap also called modified Martius flap. First described by Heinrich Martius in 1928, this approach has been continuously modified and adjusted over time and is used in the repair of various pelvic floor disorders. Overall success rates reported in the literature of the interposition of a Martius flap as an adjunct procedure in the surgical management of RVF are 65-100 %. We present a detailed description of the operation technique together with a discussion of the use of a dorsal-flapped modified Martius flap in the treatment of RVF.

The disappointing quality of published studies on operative techniques for rectovaginal fistulas: a blueprint for a prospective multi-institutional study.

Treatment of rectovaginal fistulas is difficult, and many surgical interventions have been developed. The best surgical intervention for the closure of these fistulas is still unclear. A systematic review was performed reporting the outcomes of different surgical techniques for rectovaginal fistulas. Medline (PubMed, Ovid), Embase (Ovid), and The Cochrane Library databases were searched for eligible articles as well as the references of these articles. Two independent reviewers analyzed the search results for eligible articles based on title, abstract, and described results. Any surgical intervention for the closure of rectovaginal fistulas was included. The main outcome was closure rate. Secondary outcomes were quality of life, morbidity, and the effect on sexual functioning. Many articles with different operative techniques were identified and classified in the following categories: advancement flaps (endorectal and endovaginal), transperineal closure, Martius procedure, gracilis muscle transposition, rectal resections, transabdominal closure, mesh repair, plugs, endoscopic repairs, closure with biomaterials, and miscellaneous techniques. Results vary widely with closure rates between 0% and >80%. None of the studies were randomized. Because of the poor quality of the identified studies, the comparison of results and performance of a meta-analysis were not possible.Data regarding the secondary outcomes were mostly unavailable. The major limitation of this review was the limited availability of high-quality prospective studies, making it impossible to perform a meta-analysis. No conclusion about the best surgical intervention for rectovaginal fistulas could be formulated. More large studies of high quality are needed to find the best treatment for rectovaginal fistulas. A design for these high-quality studies was formulated.

Rectovaginal fistula: a new technique and preliminary results using collagen matrix biomesh

A rectovaginal fistula (RVF) is a debilitating condition that is difficult to treat. Many available techniques are invasive and involve extensive surgery. A local procedure with good closure rates would be preferable as a first step in the treatment of RVF. The aim of this study was the development of a local technique for the closure of RVF with good closure rates to prevent the use of more invasive procedures. This was a pilot study. Patients with RVF who had undergone multiple operations in the pelvic area, local radiotherapy, chemotherapy or had been diagnosed with Crohn's disease were included in the study. All had a history of surgery for RVF. A cross-linked collagen matrix biomesh was placed in the rectovaginal septum using a transperineal or a transvaginal approach. The main outcome measure in this study was the closure rate reported as absence of the fistula at 1year. Twelve patients were included in the study. Absence of fistula at 1year was 0.64 (95% confidence interval 0.30-0.85). Three patients (25.0%) developed a recurrence, two were reoperated on with a gracilis flap transposition, and one was treated with laparoscopic ligation. In one patient (8.3%), the fistula failed to close within 3months after the mesh placement. Our technique shows promising results. A local and simple technique with acceptable closure and morbidity rates, like our local repair with biomesh, would be ideal as a first step in treating RVFs. Long-term results are needed.

Transanal endoscopic microsurgical treatment of rectovaginal fistula: an original technique

Transanal endoscopic microsurgical treatment of rectovaginal fistula: an original technique

Obstetric recto-vaginal fistula: What technique to use?

Objective: The recto-vaginal fistula is an abnormal communication between the previous wall of the rectum and the posterior face of the vagina through the recto-vaginal septum. They are often due to the obstetric traumas and they can be of post-surgical origin. Methods: We report five cases of patients with obstetric recto-vaginal fistula and all of the patients have surgical intervention with a resection of the fistulous route and rectal wall. Results: The patient did not present any recidivating and the evolution is satisfactory without complications or recidivating. Conclusion: The treatment of recto-vaginal fistula is often difficult exposed to recurrence; and the therapeutic indications must be adapted to every type of fistula by taking into account its size, its location and its etiology.

German S3-Guideline: rectovaginal fistula.

Background: Rectovaginal fistulas are rare, and the majority is of traumatic origin. The most common causes are obstetric trauma, local infection, and rectal surgery. This guideline does not cover rectovaginal fistulas that are caused by chronic inflammatory bowel disease.Methods: A systematic review of the literature was undertaken. Results: Rectovaginal fistula is diagnosed on the basis of the patient history and the clinical examination. Other pathologies should be ruled out by endoscopy, endosonography or tomography. The assessment of sphincter function is valuable for surgical planning (potential simultaneous sphincter reconstruction).Persistent rectovaginal fistulas generally require surgical treatment. Various surgical procedures have been described. The most common procedure involves a transrectal approach with endorectal suture. The transperineal approach is primarily used in case of simultaneous sphincter reconstruction. In recurrent fistulas. Closure can be achieved by the interposition of autologous tissue (Martius flap, gracilis muscle) or biologically degradable materials. In higher fistulas, abdominal approaches are used as well. Stoma creation is more frequently required in rectovaginal fistulas than in anal fistulas. The decision regarding stoma creation should be primarily based on the extent of the local defect and the resulting burden on the patient.Conclusion: In this clinical S3-Guideline, instructions for diagnosis and treatment of rectovaginal fistulas are described for the first time in Germany. Given the low evidence level, this guideline is to be considered of descriptive character only. Recommendations for diagnostics and treatment are primarily based the clinical experience of the guideline group and cannot be fully supported by the literature.

Chirurgische Versorgung und Prognose rektovaginaler Fisteln in Abhängigkeit ihrer Genese

The rectovaginal fistula is a rare entity with heterogenic causality. Its genesis seems to predict the extent of operative treatment and the prognostic outcome. The aim of this study was to present different surgical techniques in the treatment of rectovaginal fistulas and their results in correspondence to the genesis. Between 1 / 2000 and 1 / 2010, the data of patients with rectovaginal fistulas were collected. The retrospective analysis included biographic and anamnestic data as well as clinical parameters, general and specific complications and postoperative data. In a timespan of ten years 36 patients with rectovaginal fistulas were treated. The most common causes were inflammatory diseases (n = 21) and earlier surgical measures (n = 6). Moreover tumour-associated fistulas (n = 5) and fistulas with unknown genesis (n = 4) were seen. As surgical techniques anterior resection (n = 21), transrectal flap plasty (n = 7), subtotal colectomy (n = 3), pelvine exenteration (n = 2) and rectal exstirpation (n = 1) were used. The closure of the vaginal lesion was performed by single suture (n = 25), flap plasty (n = 6), transvaginal omental plasty (n = 2) and posterior vaginal plasty (n = 1). All patients were provided with an omental plasty to perform a safe division of the concerned regions. Patients with a low fistula ( < 6 cm) were treated with transperineal omental plasty. The median follow-up was 12 months (6 - 36). Within this timespan 6 patients suffered from major complications [ARDS, anastomosis insufficiency, postoperative bleeding, recurrence of fistula (n = 3)]. Three patients died in the postoperative period (cerebellar infarct, septic complication associated with Crohn's disease, multiorgan failure in tumour recurrence). The genesis of rectovaginal fistulae is an important predictor for the size of resection which can range from simple excision to exenteration. For optimal therapy the surgical intervention needs to be integrated into an interdisciplinary therapy concept.

Interposition of vital bulbocavernosus graft in the treatment of both simple and recurrent rectovaginal fistulas

The objective of the study is to assess the efficacy of vital bulbocavernosus graft transposition in the treatment of rectovaginal fistula. From March 2003 to October 2007, nine consecutive patients diagnosed with rectovaginal fistula were refereed to our institute. All patients were treated using an interposing vital bulbocavernosus graft between rectum and vagina. Median patient age was 33 years (range, 19-61) and seven of the nine patients had undergone between one and six fistula repair sessions prior to this grafting procedure. The etiology included congenital in three, surgery injury in four, obstetric in one, and radiation in one. No wound infections or abscesses occurred postoperatively, and the in-hospital mortality rate was zero. No recurrence was reported during the follow-up period and all patients had normal fecal continence. Only one patient had mild dyspareunia and no further surgical treatment needed. Both simple and complex rectovaginal fistula can be reliably repaired using a bulbocavernosus graft.