Surgical treatment of low rectovaginal fistulas

Abstract

Forty women with low rectovaginal fistulas were operated upon over a 9-year period. The etiology of the fistula in the majority was obstetric. Nine women had prior attempts to repair the fistula. All 40 women were managed with endorectal advancement flap with the addition of sphincteroplasty or perineal body reconstruction in 15 patients and rectocele repair in six patients. Postoperative complications included urinary difficulties (two patients) and wound complications (three patients). There were two recurrences. All women treated with sphincteroplasty or perineal body reconstruction were continent. Seven women complained of varying degrees of incontinence postoperatively; none had undergone sphincter or perineal body reconstruction. Endorectal advancement flap is a safe and effective operation for women with rectovaginal fistulas. Concomitant sphincteroplasty or perineal body reconstruction should be performed in women with historical, physical, or manometric evidence of incontinence.

Benign rectovaginal fistulas: management and results of a personal series

“…Although some reports [2,6,7] have shown no improvements in the outcome of an advancement flap with a concomitant sphincteroplasty or puborectal sling interposition [8], other authors [10,13] clearly demonstrated the benefit of sphincteroplasty, especially in complex fistulas after previous failed repair or if a traumatic sphincter disruption is present [6,13]. In the present series, fistulectomy and sphincteroplasty was the most successful technique in the treatment of simple fistulas, but we also advocate the selection of that technique as the first option in the previously mentioned cases.…”

“…Results of endorectal advancement flap in the treatment of simple fistulas have been initially very good but it has been also demonstrated that the success rate drops with the number of previous procedures [2,6] and, more recently, several studies have reported a significantly lower healing rate [7][8][9][10]. The vaginal flap follows the same surgical principles as the rectal flap and shows no curative advantages over it, except in those cases were the rectal flap has already failed or it is not indicated due the anatomical or pathological conditions of the anorectum, as in patients with Crohn's disease or ulcerative colitis.…”

Puborectal sling interposition for the treatment of rectovaginal fistulas

“…Comparing the Rockwood fecal incontinence severity index score before and after the procedure, no significant differences were found. After transanal advancement flap repair, impairment of fecal continence does occur in a substantial number of patients [7,24].…”

“…Based on these data it seems obvious that closure of the anal opening, by a transanal advancement flap repair, is not the only key to successful repair. Impairment of continence, observed in a substantial number of patients, is another drawback of this procedure [7,24]. In an attempt to improve the results, we added labial fat flap transposition to the advancement flap repair.…”

“…Puborectal sling interposition for the treatment of rectovaginal fistulas between 78% and 95% [4,[6][7][8]. More recently, however, a significantly lower healing rate has been reported, especially in women who had previous repairs [9][10][11].…”