Sie sind auf Seite 1von 43

Expert Review of Gastroenterology & Hepatology

ISSN: 1747-4124 (Print) 1747-4132 (Online) Journal homepage: http://www.tandfonline.com/loi/ierh20

Management of rectovaginal fistulas and patient


outcome

Mahmoud Abu Gazala & Steven D. Wexner

To cite this article: Mahmoud Abu Gazala & Steven D. Wexner (2017): Management of
rectovaginal fistulas and patient outcome, Expert Review of Gastroenterology & Hepatology, DOI:
10.1080/17474124.2017.1296355

To link to this article: http://dx.doi.org/10.1080/17474124.2017.1296355

Accepted author version posted online: 21


Feb 2017.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at


http://www.tandfonline.com/action/journalInformation?journalCode=ierh20

Download by: [University of Newcastle, Australia] Date: 21 February 2017, At: 16:33
Publisher: Taylor & Francis

Journal: Expert Review of Gastroenterology & Hepatology

DOI: 10.1080/17474124.2017.1296355
Review

Title: Management of rectovaginal fistulas and patient outcome

Authors Mahmoud Abu Gazala and Steven D. Wexner

Affiliation

Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL

*Corresponding author

Steven D. Wexner

Cleveland Clinic Florida, Department of Colorectal Surgery, 2959 Cleveland Clinic Blvd,

Weston, FL 33331

Tel: 954-659-6020

Email: wexners@ccf.org
ABSTRACT

Introduction: Rectovaginal fistulas are a relatively rare, but debilitating condition which pose a

significant treatment challenge.

Areas covered: In this manuscript we discuss the etiology, classification as well as the

manifestations and evaluation of rectovaginal fistulas. We summarize the different surgical

techniques and evaluate their success rates and perioperative considerations according to cited

sources.

Expert commentary: A deep understanding of the disease, treatment options, and familiarity

with the different surgical treatment options available is mandatory for choosing the correct

treatment. When the surgical treatment is tailored to the specific fistula and patient, many

patients can eventually have successful resolution. This review will address the management

and patient outcomes after treatment for rectovaginal fistulas.

Keywords: Advancement flap, Crohn’s disease associated fistulas, Radiation induced

fistulas, Gracilis interpositioning, Martius flap, Obstetric trauma, Rectovaginal fistula, Surgical

repair.
1. INTRODUCTION

Rectovaginal fistulas (RVFs), although relatively rare, can represent a devastating and disabling

condition for the patient, due to both psychological and physical sequelae. Its treatment also

poses great challenges for the colorectal surgeon. RVFs are abnormal epithelium lined

communications between the rectum and the vagina. Anovaginal fistulas arising from the anal

canal, inferior to the dentate line, are not true RVFs.

2. ETIOLOGY

RVFs may be acquired or congenital. In this review we will discuss only the acquired RVFs,

which account for about 5% of anorectal fistulas. (1) However, it is difficult to assess the exact

incidence and prevalence of RVFs due to their relative rarity, lack of structured reporting, and

small number of patients included in the published series. It is also difficult to ascertain the

precise incidence of the different etiologies due to the referral patterns to various surgeons and

institutions. Nevertheless, the most common etiologies for RVFs are traumatic, mainly obstetric,

followed by Crohn's disease, cryptoglandular disease, malignancy, radiation, and other

iatrogenic complications.

Mechanisms for development of RVFs in obstetric trauma include prolonged or obstructed labor

with possible development of pressure necrosis of the rectovaginal septum. This mechanism is

more prevalent in underdeveloped countries. RVFs may also develop following unrecognized

3rd or 4th degree perineal tears, disrupted repair of perineal tears, or episiotomy sites due to

technical factors or infection. They may also be a consequence of traumatic injury during

instrumented delivery. The incidence of RVFs following vaginal delivery was reported by

Venkatesh et al (2) to be in the range of 0.1-0.5%.


Rarely, traumatic RVFs can occur as a part of multiorgan blunt or penetrating injury. As injured

tissue is usually well-vascularized and not otherwise diseased, good results can be expected

with surgical repair. Other causes of traumatic RVFs include sexual violence with forceful

penetration and use of foreign bodies, which may unfortunately result in large defects.

The rectovaginal septum is quite thin above the anal sphincter complex. Any surgical dissection

in this area runs the risk of injury and resultant RVF. During a proctectomy with colorectal, or

coloanal, or ileal pouch anal anastomosis, the vaginal wall may be inadvertently incorporated

into the stapler, resulting in a RVF. A similar mechanism may be causative during stapled

hemorrhoidectomy procedures ortransanal excisional procedures.

Approximately 5-10% of women with Crohn's disease will develop RVF, related to Crohn's

disease activity in the large bowel. RVFs secondary to Crohn's disease are a risk factor for

ultimate proctectomy. (3, 4)

Early RVFs occur during radiation treatment as a result of tumor regression where the tumor

has fully or partially invaded the rectovaginal septum. However, most radiation-induced RVFs

occur 6-24months after treatment. Mechanisms of such fistula formation include chronic

radiation injury to the rectal and vaginal walls, resulting in inflammatory and ulcerative damage

due to progressive endarteritis obliterans and tissue hypoxia that gradually leads to fistula

formation. Risks for radiation-induced RVFs include dose of radiation and vascular disease risk

factors such as diabetes, smoking, and hypertension. The risk is also higher in patients who

have had abdominal or pelvic surgery. (5) It is imperative to distinguish radiation-induced RVFs

from tumor recurrence. In addition, cancers can be noted in chronic fistula tracts.

RVFs can also occur following treatment of gynecological and other malignancies, following

cryptoglandular infection, or, rarely, from stercoral ulcers from fecal impaction, use of pessaries,

and/or mesh placement.


3. CLASSIFICATION

Rectovaginal fistulas can be classified on the basis of etiology, size and location. Daniels

classified RVFs based on their location. (6) Fistulas arising from the distal third of the rectum to

the lower half of the vagina are considered “low” RVFs and are generally amendable to a

perineal approach. “High” RVFs are located between the middle third of the rectum and the

upper half of the vagina and usually require a transabdominal approach.

Location of the fistula varies based on the specific mechanism and etiology. Fistulas following

pressure necrosis of the rectovaginal septum and due to traumatic instrumented delivery are

usually high, where the rectovaginal septum is thin. (7) Fistulas following perineal tears are

usually low, at the level of the sphincters.

Rothenberger et al. (8) classified RVFs as “simple” when located in the lower or middle third of

the vagina, are caused by trauma or infection, and have a diameter ≤ 2.5cm.Conversely, RVFs

are considered “complex“ when they arise in the upper rectovaginal vaginal septum, have a

diameter ≥ 2.5cm, and occur following inflammatory bowel disease (IBD), radiation, or cancer.

Repeated failed repairs also define the fistula as complex.

4. CLINICAL MANIFESTATIONS, EVALUATION, AND DIAGNOSIS

Symptoms of RVF greatly vary and are dependent on the size, location, and etiology of the

fistula. Most patients with RVF complain of uncontrolled passage of gas or stool through the

vagina. Stool passage is worse with diarrhea and larger defects in the rectovaginal septum.
Other symptoms include purulent, foul-smelling vaginal discharge, dyspareunia, perianal pain,

vaginal irritation, and recurrent genitourinary tract infections. Fecal incontinence could indicate

anterior disruption of the external anal sphincter. Such involvement of the anal sphincter may

alter the treatment options chosen. In patients with Crohn’s-related RVF or following malignancy

or radiation, the clinical picture may further be complicated by concomitant pathologies such as

stricture or inflammatory response.

The presence of RVF is commonly accompanied by great emotional distress. Accurate

assessment of the RVF may not be possible in the office setting, and might be undertaken in the

operating room under anesthesia. Presence, location, size, and associated pathologies and

underlying diseases should all be carefully assessed in the operating room, as well as exclusion

of accompanying sepsis, untreated collections, or malignancy. Integrity of the anal sphincter

complex should be ascertained. One in three women with RVF may suffer from concomitant

sphincter injury. Failure to identify sphincter complex involvement in RVF may result in

continued or worsening fecal incontinence and/or failure of advancement flap repair. (9)

Small or high fistulas may be difficult to identify by physical examination alone. In one series,

physical examination alone was successful in identifying up to 74% of RVFs. (10)

Additional evaluative studies may be necessary to better identify and evaluate patients with

RVF. These include the methylene blue tampon test, computed tomography (CT) scan,

magnetic resonance imaging (MRI), endorectal ultrasound (EUS), gastrograffin enema (GGE),

vaginography, fistulography, and enteroscopy. MRI and EUS are the most useful imaging

modalities in identifying RVF,(11) and are especially beneficial in the evaluation of sphincter

involvement. The presence or exclusion of additional concomitant fistulas to other organs is also

essential for treatment planning. As previously mentioned, a high index of suspicion should be

maintained to exclude malignancy.


5. PREOPERATIVE CONSIDERATIONS

The management approach for patients with RVF is largely dependent on several factors.

Fistula age, size, location, etiology, symptomatology, quality of surrounding tissue, prior surgical

treatment attempts, as well as patient factors including comorbidity, all play an important role in

the decision-making process. It has been suggested that up to half of the acute small RVFs

caused by obstetric injury may spontaneously heal. (12)

Care should be taken in the treatment of accompanying infection or inflammation. Drainage of

untreated collections, as well as antibiotics, seton placement, and local care should be provided

to allow tissue healing prior to definitive surgical treatment. Occasionally, in order to achieve

satisfactory symptom control and adequate tissue healing, stool diversion maybe necessary. In

some cases, stool diversion, accompanied by local treatments and sepsis control, may be

adequate to allow for spontaneous healing of the fistula. Reassessment for ongoing sepsis

should be performed with confirmation of resolution of active inflammation. Once tissue healing

has occurred with persistence of a mature RVF, directed surgical intervention could be

considered.

Small and asymptomatic RVFs may be treated by dietary modification and fiber

supplementation in an attempt to prevent diarrhea.

The surgical approach is specifically tailored to each fistula and patient, and at times a

combination of several surgical approaches is required. The choice of surgical approach is

dictated by fistula location and etiology. Low fistulas are potentially amendable to local repair

(transanal, transvaginal or trans-perineal approach), while high fistulas can generally be treated

via trans-abdominal approach. Regardless of the surgical approach, all patients should be

preoperatively counseled that multiple operations, including a stoma, may be required to


achieve healing. In addition, patients should understand the possibility of ultimate treatment

failure.

6. SURGICAL APPROACH

Anovaginal fistulas without sphincter involvement are potentially amendable to fistulotomy or

fistulectomy. However, because of the risk of fecal incontinence, fistulotomy is often avoided.

RVFs involving the anal sphincter complex or located higher in the rectovaginal septum can be

approached using different methods, including local repair, use of biomaterials, and tissue

transposition repairs. A possible therapeutic approach is summarized in algorithm 1, and the

different surgical approaches are herein detailed.

6.1 Local Repair

Local repair of RVF can be accomplished using transanal, transvaginal, or trans-perineal

approaches. There has been an immense diversity of different variations described in the

literature.

Acute RVF due to obstetric injury may be amendable to immediate primary repair, with or

without sphincteroplasty. It is of immense importance to achieve adequate hemostasis and

exposure of the operative field and correct identification of the anatomy. The vagina can be

packed during the repair to improve vision from uterine bleeding. The edges of the internal and

external sphincters must be identified clearly to ensure accurate repair. The repair should be

performed in a multilayered fashion: Initially, the rectal mucosa is repaired using a 2-0 braided

absorbable suture starting from the most proximal edge of the tear distally. Next, the internal

sphincter is identified and repaired as a separate independent layer using long-term interrupted
2-0 absorbable sutures. It should be noted that once the sphincter is severed, it retracts

superiorly and laterally. Repair of the internal sphincter is of great importance for the strength

and integrity of the repair and for achieving maximal continence. Next the external sphincter is

identified and repaired in an end-to-end or overlapping fashion using interrupted or figure-of-

eight long-term absorbable 2-0 sutures. Mobilization of the sphincter halves may be necessary

to achieve adequate repair. No apparent long-term difference between end-to-end vs

overlapping sphincteroplasty has been demonstrated in several trials. (13, 14)

Once satisfactory repair of the sphincter complex has been achieved, subsequent repair of the

distal rectovaginal septum and perineal body is performed. The goal of the surgical repair is

reconstruction of a long anal canal, an intact sphincter complex, perineal body and rectovaginal

septum. Great care should be given for sepsis prevention using copious irrigation and

hemostasis, in addition to perioperative antibiotic coverage.

Surgery is deferred in patients who develop late RVF due to obstetric injury, such as

rectovaginal septum necrosis, infection and/or disruption of fourth degree perineal laceration.

One of the methods for local transperineal repair of RVFs involving the anal sphincter complex

includes conversion of the fistula to a fourth-degree perineal laceration. The fistula tract is then

debrided or excised, the sphincter muscles are identified and dissected as are rectal and

vaginal walls, which are then repaired in a multi-layered fashion. Anal overlapping

sphincteroplasty or levatorplasty can be performed in these patients, which allows for a mass of

muscle to interpose between the rectal and vaginal repair. This approach is especially

appropriate in patients with concomitant anterior sphincter defect and fecal incontinence.

Several variations of this technique have been described in the literature, including in

combination with rectal and vaginal advancement flaps and the use of interpositioning

bioprosthetic grafts, (15,16) with success rates ranging from64-100%. (17) This approach may

be preferable in the presence of a concomitant anterior sphincter defect. In higher fistulas


without sphincter involvement, an anterior transvaginal levatoroplasty can be performed with

excellent results as recently described by Maeda et al. (18)

There has been growing popularity for treatment of perianal fistulas using the LIFT (ligation of

intersphincteric fistula tract) procedure. There has been limited experience with this technique in

the treatment of RVF. However, in patients with low RVF involving the anal sphincter complex,

LIFT is a feasible alternative, which does not compromise the function of the anal sphincters.

This procedure involves dissecting the avascular intersphincteric plane between the internal and

external anal sphincters. (Figure 1) The fistula tract is identified, isolated, and divided on both

sides between sutures. (Figures 2 and 3) Bioprosthetic material may be inserted to separate

ends of divided tract. (Figure 4)

Transanal approaches for repair of RVF involve closure of the rectal side of the fistula. This

method theoretically has the advantage of repair on the higher-pressure side, which serves to

buttress the repair. Different techniques have been described, with the endorectal advancement

flap first described by Noble in 1902, being considered by many colorectal surgeons as the

procedure of choice, especially for low RVF. The procedure consists of outlining and raising a

flap of mucosa, submucosa, and the circular muscle layer. (Figure 5,6,7) The flap extends at

least 3-4 cm cephalad to the fistula, with the base of the flap twice the width of the apex to allow

adequate blood supply to the flap tip. Alternatively, a 120°-180°anterolateral circumferential

elliptical flap can be raised without dividing the flap in a caudal-to-cephalad direction. The fistula

opening on the rectal side is excised and the opening is derided and closed. It is possible to

approximate the lateral edges of the muscular layer over the fistula opening as an additional

layer of reinforcement. (Figure 8) The flap is then advanced over the internal opening of the

RVF, thus covering it by healthy tissue. (Figure 9) The vaginal side of the fistula is often left

open for drainage.


In theory, this approach does not interfere with continence since the external sphincter is not

disturbed. (19) Furthermore, in cases of fecal incontinence or transsphincteric RVF, this

procedure can be combined with overlapping sphincteroplasty. This approach separates the

suture line from the fistula site and interposes healthy muscle between the rectal and vaginal

walls. The overall success rate ranges from 43-93% (Table 1) (19,20, 21,22,23,24). Postulated

advantages of the transvaginal advancement flap include greater redundancy in the posterior

vaginal wall than the anterior rectal wall and avoidance of suturing inflamed rectal mucosa.

However, a disadvantage is that the fistula is repaired from the low-pressure side of the fistula,

where the relatively higher rectal pressure may theoretically disrupt the repair. Though not a

direct comparative study, Ruffolo et al (25) performed a systematic review of the literature and

found no significant difference between transrectal and transvaginal advancement flaps for

treatment of RVF in Crohn's patients, in terms of fistula closure rates.

6.2 Use of biosynthetic products

There have been several repair techniques using biosynthetic products developed for fistula

tract closure. The advantages of these procedures are that no tissue dissection is required, the

relatively easy application, and the lack of long-term consequences in case of failure. These

purported advantages explain their use by some surgeons as the first line of treatment for

perianal and rectovaginal fistulas.


The rationale behind use of biomaterials for fistula closure is that they provide a biologic matrix

promoting inflammatory response and scar formation, thus enabling fistula closure. Fibrin glue

has had low success rates, and thus is rarely indicated. (26) The collagen fistula plug has been

used more widely with better rates of success. It consists of a cylindrical plug made of acellular

collagen matrix, which is lodged into the previously debrided fistula tract and secured in place

by sutures on both fistula openings. (Figure 10) The plug promotes an inflammatory response,

which is gradually replaced by scar tissue. The design of the rectovaginal fistula plugwas altered

from anorectal fistula plugs to include additional components such as a button on the rectal

side. Success rates are usually low, in the range of 20-35%; however, success rates of up to

85% have been reported. (26, 27, 28, 29)

Biosynthetic materials can be implanted in combination with other procedures for fistula closure,

such as endorectal flap advancement. In addition, biosynthetic materials, such as biologic

mesh, can be used to separate both ends of divided fistula tract in transperineal repairs and the

LIFT procedure. (Figure 4)

6.3 Tissue transposition repairs

The rationale behind tissue transposition repairs is to interpose healthy, well-vascularized tissue

between the cut edges of the RVF tract. The added bulk of tissue, in combination with its unique

vascularity, allows for enhanced blood supply to the area, obliteration of dead space, and

protection of the suture lines on both the rectal and vaginal sides. These repairs allow for very

high success rates for RVF repair, but with the cost of added procedural complexity and the

need for fecal diversion.


A wide array of muscles and pedicled adipose tissue has been described in the literature. Of

these, the most widely used are the gracilis muscle and the Martius flap. Other options include

the sartorius muscle and the omentum.

The Martius flap, first described by Dr. Heinrich Martius in 1928, uses the labial fat with

bulbocavernosus/bulbospongiosus muscle for reconstruction. The flap is mobilized, preserving

its posteriolateral vascular pedicle, which originates from internal pudendal artery branches. The

flap is then rotated and interposed between the cut and closed edges of the RVF, taking

extreme care not to torque its blood supply. One problem with this flap is its small size and

limited blood supply. Success rates for this procedure range between 60-100% in different

series. Pitel et al. (30) reviewed their experience with 20 patients with RVF treated using the

Martius flap technique; 40% of the fistulas were due to Crohn's disease. They reported an

overall success rate of 60%, and a success rate of 50% in patients with Crohn's disease.

Songne et al. (31) reported their experience with 14 patients with RVF treated with the Martius

flap. Seven patients had Crohn's disease and four had a pouch-vaginal fistula. Their

postoperative success rate at 3 months was 100%.

The gracilis muscle interposition offers a greater bulk of healthy vascularized tissue to allow

tissue healing. The procedure consists of harvesting the gracilis muscle from the thigh, using

either a single longitudinal incision over the medial aspect of the thigh or 2 smaller incisions.

The muscle is mobilized, dividing its perforating blood supply, and transecting its insertion to the

tibial plateau. Care should be taken to preserve its neurovascular bundle at its origin. The

muscle is then passed through a tunnel from the proximal aspect of the thigh towards the

perineum, and is then interposed between the rectum and vagina, which have been dissected

apart and the RVF is divided. The fistula openings on both sides are debrided and closed

primarily or using an advancement flap. Extreme care should be taken not to torque the

muscle’s blood supply nor to apply excessive tension on the neurovascular bundle.
Wexner et al. (32) reported a success rate of 75% in gracilis muscle interposition for RVFs in a

series of 8 women without Crohn’s disease and an initial success rate of 33% in 9 women with

Crohn’s disease. Pinto et al. (22) reported their experience with 24 patients with RVFs treated

with gracilis muscle interposition. Their overall success rate was 79%, and 66% in patients with

Crohn's disease. Furst et al. (33) reported a 92% success rate in treatment of recurrent

rectovaginal fistulas in patients with Crohn's disease (Table 2). (22,32,33,34,35,36)

This option is generally reserved for patients in whom multiple other fistula repairs have failed.

6.4 Trans-Abdominal Approach

A trans-abdominal approach for the treatment of RVFs may be indicated in high RVFs,

originating from the middle third of the rectum to the upper portion of the vagina, or in patients

with a severely damaged rectum such as after radiation. The exact procedure depends on the

specific anatomy of the fistula, the patient's condition and will, and also the condition of the local

tissue. When the patient has a high fistula with relatively healthy surrounding tissue, anterior

dissection between the rectum and the vagina is performed, with division of the fistula tract and

possible interposition of an omental flap. In a prospective study by Van der Hagen et al, (37)

laparoscopic fistula division and closure followed by an omentoplasty was attempted in 40

patients. The procedure was feasible in 38 patients (95%), only two of whom had a recurrence.

In cases when local repair is not feasible, especially in patients with radiation damage, IBD or

neoplasm, resection of the diseased rectum with anastomosis at a lower level is necessary. In

an article from 1986, Cooke and Wellsted (38) reported a success rate of 93% in the treatment

of 42 patients who had received radiotherapy and had undergone proctectomy for RVF. More
recently, Schouten et al (39) described their series of 8 women who underwent rectal sleeve

advancement for the treatment of persistent RVF. Their overall success rate was 75%.

7. Special considerations

Radiation induced fistulas

As previously mentioned, high or low RVF can develop due to invasive tumor regression or

chronic radiation injury. Low RVF may be amendable to local repair, although diffuse tissue

injury and scaring make the dissection of the fistula difficult and local microvascular injury may

significantly compromise success. These problems often prompt the use a healthy, non-radiated

and well-vascularized interposition graft. High fistulas can be repaired via a transabdominal

approach, using an interposition omental flap or rectus abdominus. In case of severely

damaged local tissue, it may be necessary to perform the resection and anastomosis at a lower

level. Temporary diversion should be considered for all radiation-related fistulas. Permanent

colostomy should be considered in patients with severe radiation injury.

RVFs due to Crohn's disease

In patients with Crohn's disease-induced RVF, disease activity, both in the rectum and in the

rest of the gastrointestinal tract, should carefully be determined. Other factors affecting

treatment approach include symptoms, quality of life, rectal compliance, and continence status.

Disease activity should be controlled using anti-TNF drugs and other anti-inflammatory

medications. Sepsis control is ideally accomplished with seton placement. Inflammation and

sepsis should be controlled prior to attempted repair.


As Crohn'sis a chronic, recurrent, and relapsing disease, the management approach of RVF in

these patients differs from other etiologies, and should generally be more conservative.

Minimally symptomatic patients may not require surgical intervention. In some cases, medical

treatment may induce spontaneous healing of the RVF. In the ACCENT II study, Sands et al.

(40) reported a 64% response rate (defined as reduction of 50% in number of fistulas at the10-

week follow-up) at the 14-week follow up in patients with RVF who received Infliximab;72% of

responders had no sign of active RVF at the 14-week follow up.

Long-term fistula control by means of a non-cutting seton is a valid option as a sphincter-

preserving procedure in select patients, namely those with active disease who cannot undergo

surgical repair. (41,42)

Local surgical repair may be considered for patients with a persistent, mature, single fistula and

healthy non-inflamed rectal mucosa. Anal sphincter repair should also be performed in patients

with impaired continence. Numerous local repairs, transabdominal approaches, and tissue

transfer repairs have been described. (43)

Patients who fail to achieve disease control and suffer from severe disease refractory to

maximal medical management and have had seton placement may be candidates for

proctectomy.

Stoma

Fecal diversion has several uses in the treatment of RVF. Patients with severe symptoms

resulting from the RVF or who suffer from debilitating active Crohn's disease or radiation

proctitis may benefit from fecal diversion to allow tissue healing and symptom relief. In some
cases, stoma may be the definite treatment for patients with RVF, especially in those with

impaired continence.

Other considerations for stoma creation should include the magnitude of planned surgery and

contribution of fecal diversion for promotion of repair success. In cases of recurrent RVF, major

pelvic dissection, damaged local tissue, and in tissue transposition procedures, fecal diversion

should be considered. No definitive data is available if the mere existence of the stoma reduces

the risk for RVF recurrence, but usually, patients who undergo fecal diversion are theoretically

suffering from more complex disease.

8. Outcome of RVF repair

The success rates for surgery for RVF may depend on several factors including etiology,

characteristics of the specific fistula, condition of the surrounding tissue, history of prior surgical

repair, presence of inflammation or infection, comorbidities, and type of surgery selected.

In a review of our experience over a period of two decades, 184 procedures were performed on

125 patients with RVF. The success rate after the first procedure was 57%, and the overall

success rate per patient was 87%. (22)

In our attempt to define the risk factors for fistula recurrence, several were identified. Tobacco

smoking had a higher risk of recurrence with an odds ratio of 1.94. Patients with Crohn's

disease as an etiology for the RVF also had a significantly higher risk of recurrence compared to

other etiologies. The success rate per procedure was 44.2% and 78% per patient after a mean

of 1.8 procedures.
Patients who had recurrent RVF had higher risk of procedure failure. The greater the number of

prior repair attempts, the higher the recurrence rate. In our experience, the success rate for

initial RVF repair was 67%, which dropped to 50% for repair of recurrent RVF. Lowry et al. (44)

had previously reported a similar trend. Despite this, revisional surgery is possible and

successful in most patients. Halverson et al. (45) reported an overall success rate of 79% after a

mean of two procedures for the treatment of recurrent RVFs in their series of 35 women. Timing

of revisional surgery may also be of importance. While some studies failed to demonstrate a

connection, others had better results with an interval time of at least 3 months between repairs.

(22,45)

9. CONCLUSION

Rectovaginal fistulas pose a significant challenge. A thorough understanding of the disease,

treatment options, and familiarity of the different surgical treatment options available is

mandatory for choosing treatment. When the surgical treatment is tailored to the specific

fistula and patient, many patients can eventually have a successful outcome.

10. EXPERT COMMENTARY AND FIVE-YEAR VIEW

Rectovaginal fistulas pose a special challenge as they are relatively rare, diverse in etiology,

location and challenging to treat. A myriad of different treatment options is a testament to the

lack of a panacea therapy. Due to this significant heterogeneity in the etiology and treatment

options, it is difficult to conduct meaningful large randomized controlled trials. In the absence of

conclusive data from such trials, the management plan and surgical approach should still

be tailored to the specific fistula and patient. A thorough understanding of the disease and
familiarity with the different surgical treatment options is mandatory to try to optimize the

opportunities for success.

Future directions which may evolve in the treatment of RVFs may include advances in both

medical and surgical pathways. Novel research is directed at reducing radiation damage to

normal tissue, thus potentially reducing the risk for RVFs in patients undergoing radiation

therapy. Future advancements in the medical treatment of Crohn's disease may contribute

to RVF prevention and yield greater success rates. Other advances in the field of

biosynthetic plugs may also enhance closure rates. There have also been several reports of

novel treatment options for RVFs such fat injection (46) and autologous stem cell

transplantation. (47, 48) Other advances in endoscopic treatment options may offer additional

armamentarium for the treatment of RVFs such as endoscopic clips and self-expanding metal

stents. (49, 50)

11. KEY ISSUES

Rectovaginal fistulas (RVFs) represent a relatively rare debilitating condition. The most

common etiologies for RVFs are traumatic, mainly obstetric, followed

by Crohn's disease, cryptoglandular disease, malignancy, radiation, and other iatrogenic

complications.

RVFs have been classified as “simple” when located in the lower or middle third of the

vagina, are caused by trauma or infection, and have a diameter ≤ 2.5cm. Conversely,

RVFs are considered “complex“ when they are recurrent, arise in the

upper rectovaginal vaginal septum, have a diameter ≥ 2.5cm, and occur following

inflammatory bowel disease (IBD), radiation, or cancer.


The management approach for patients with RVF is complex and depends on several

factors including size, location, etiology, symptomatology, quality of surrounding tissue,

prior surgical treatments, as well as patient factors including comorbidity.

A thorough understanding of the disease and familiarity with the different surgical

treatment options is mandatory.

Local sepsis or inflammation should be addressed to allow tissue healing prior to

definitive surgical treatment.

Preoperative evaluation should include assessment of the integrity of the anal sphincter

complex. Failure to identify sphincter complex involvement in RVF may result in

continued or worsening fecal incontinence and/or failure of the surgical repair.

The surgical approach is specifically tailored to each fistula and patient, and at times a

combination of several surgical approaches is required.

Low fistulas are potentially amendable to local repair (transanal, transvaginal or trans-

perineal approach), while high fistulas can generally be treated via trans-abdominal

approach.

When the surgical treatment is tailored to the specific fistula and patient, many patients

can eventually have a successful repair.


Funding

This paper was not funded.

Declaration of Interest

The authors have no relevant affiliations or financial involvement with any organization or entity

with a financial interest in or financial conflict with the subject matter or materials discussed in

the manuscript. This includes employment, consultancies, honoraria, stock ownership or

options, expert testimony, grants or patents received or pending, or royalties.


References

Reference annotations

* Of interest

** Of considerable interest

1. Tsang C B, Rothenberger D A. Rectovaginal fistulas. Therapeutic options. SurgClin

North Am. 1997;77:95–114.

2. Venkatesh KS, Ramanujam PS, Larson DM, Haywood MA. Anorectal complications of

vaginal delivery. Dis Colon Rectum. 1989;32(12):1039-41.

3. Hannaway CD, Hull TL. Current considerations in the management of rectovaginal

fistula from Crohn's disease. Colorectal Dis. 2008;10(8):747-55;

4. Zhu YF, Tao GQ, Zhou N, Xiang C. Current treatment of rectovaginal fistula in Crohn's

disease. World J Gastroenterol. 2011;17(8):963-7.

5. Anseline PF, Lavery IC, Fazio VW, Jagelman DG, Weakley FL. Radiation injury of the

rectum: evaluation of surgical treatment. Ann Surg.1981;194(6):716-24.

6. Daniels B T. Rectovaginal Fistula: A Clinical and Pathological Study [master's thesis].

Minneapolis: University of Minnesota Graduate School; 1949.

7. Clinical gynecology – T.F. Kruger, M.H. Botha – 2007. Page 459.

8. * Rothenberger D A, Goldberg S M. The management of rectovaginal fistulae. SurgClin

North Am. 1983;63:61–79.

* Classification of rectovaginal fistulas to simple and complex.

9. Corman ML. Anal incontinence following obstetrical injury. Dis Colon Rectum.

1985;28(2):86-9.
10. Baig MK, Zhao RH, Yuen CH, Nogueras JJ, Singh JJ, Weiss EG, Wexner SD. Simple

rectovaginal fistulas. Int J Colorectal Dis. 2000;15(5-6):323-7.

11. Stoker J, Rociu E, Schouten WR, Laméris JS. Anovaginal and rectovaginal fistulas:

endoluminal sonography versus endoluminal MR imaging. AJR Am J Roentgenol.

2002;178(3):737-41.

12. Homsi R, Daikoku NH, Littlejohn J, Wheeless CR Jr. Episiotomy: risks of dehiscence

and rectovaginal fistula. ObstetGynecolSurv.1994;49(12):803-8.

13. Rygh AB, Körner H. The overlap technique versus end-to-end approximation technique

for primary repair of obstetric anal sphincter rupture: a randomized controlled study.

ActaObstetGynecol Scand. 2010 Oct;89(10):1256-62.

14. Fernando RJ1, Sultan AH, Kettle C, Thakar R. Methods of repair for obstetric anal

sphincter injury. Cochrane Database Syst Rev. 2013 Dec 8;(12):CD002866.

15. Lowry AC, Thorson AG, Rothenberger DA, Goldberg SM.Repair of simple rectovaginal

fistulas. Influence of previous repairs.Dis Colon Rectum. 1988 Sep;31(9):676-8.

16. Ellis CN. Outcomes after repair of rectovaginal fistulas using bioprosthetics.Dis Colon

Rectum. 2008;51(7):1084-8.

17. Göttgens KW, Smeets RR, Stassen LP, Beets G, Breukink SO. Thedisappointing quality

of published studies on operative techniquesfor rectovaginal fistulas: a blueprint for a

prospective multiinstitutionalstudy. Dis Colon Rectum. 2014;57:888-898

18. Maeda K, Koide Y, Hanai T, Sato H, Masumori K, Matsuoka H, Katsuno H. The long-

term outcome of transvaginal anterior levatorplasty for intractable rectovaginal fistula.

Colorectal Dis. 2015 Nov;17(11):1002-6.


19. Jarrar A, Church J. Advancement flap repair: a good option for complex anorectal

fistulas. Dis Colon Rectum. 2011;54(12):1537-41.

20. Sonoda T, Hull T, Piedmonte MR, Fazio VW.Outcomes of primary repair of anorectal

and rectovaginal fistulas using the endorectal advancement flap.Dis Colon Rectum.

2002;45(12):1622-8.

21. Kodner IJ, Mazor A, Shemesh EI, Fry RD, Fleshman JW, Birnbaum EH.Endorectal

advancement flap repair of rectovaginal and other complicated anorectal fistulas.

Surgery. 1993;114(4):682-9; discussion 689-90.

22. ** Pinto RA, Peterson TV, Shawki S, Davila GW, Wexner SD. Are there predictors of

outcome following rectovaginal fistula repair? Dis Colon Rectum. 2010;53(9):1240-7.

** Predictors of outcome of RVF repair. Largest series of endorectal advancement

flap for treatment of RVFs. Largest series of gracilis muscle interposition for

treatment of RVFs.

23. Jones IT, Fazio VW, Jagelman DG. The use of transanal rectal advancement flaps in the

management of fistulas involving the anorectum. Dis Colon Rectum. 1987; 30(12):919-

23.

24. Joo JS, Weiss EG, Nogueras JJ, Wexner SD. Endorectal advancement flap in perianal

Crohn's disease. Am Surg. 1998; 64(2):147-50.

25. Ruffolo C, Scarpa M, Bassi N, Angriman I.A systematic review on advancement flaps for

rectovaginal fistula in Crohn's disease: transrectal vs transvaginal approach. Colorectal

Dis. 2010;12(12):1183-91.
26. Corte H, Maggiori L, Treton X, Lefevre JH, Ferron M, Panis Y. Rectovaginal Fistula:

What Is the Optimal Strategy?: An Analysis of 79 Patients Undergoing 286 Procedures.

Ann Surg. 2015 Nov;262(5):855-60;

27. Gonsalves S, Sagar P, Lengyel J, Morrison C, Dunham R. Assessment of the efficacy of

the rectovaginal button fistula plug for the treatment of ileal pouch-vaginal and

rectovaginal fistulas. Dis Colon Rectum. 2009;52(11):1877–1881.

28. Schwandner O, Fuerst A. Preliminary results on efficacy in closure of transsphincteric

and rectovaginal fistulas associated with Crohn's disease using new biomaterials.

SurgInnov. 2009;16(2):162-8.

29. Gajsek U, McArthur DR, Sagar PM. Long-term efficacy of the button fistula plug in the

treatment of Ileal pouch-vaginal and Crohn's-related rectovaginal fistulas. Dis Colon

Rectum. 2011;54(8):999-1002.

30.* Pitel S, Lefevre JH, Parc Y, Chafai N, Shields C, Tiret E. Martius advancement flap for

low rectovaginal fistula: short- and long-term results. Colorectal Dis. 2011

Jun;13(6):e112-5.

* Large series of Martius flap for treatment of RVFs.

31.* Songne K, Scotté M, Lubrano J, Huet E, Lefébure B, Surlemont Y, Leroy S, Michot F,

Ténière P. Treatment of anovaginal or rectovaginal fistulas with modified Martius graft.

Colorectal Dis. 2007;9(7):653-6.

* Large series of Martius flap for treatment of RVFs.

32.* Wexner SD, Ruiz DE, Genua J, Nogueras JJ, Weiss EG, Zmora O. Gracilis muscle

interposition for the treatment of rectourethral, rectovaginal, and pouch-vaginal fistulas:

results in 53 patients. Ann Surg. 2008;248(1):39-43.


* Second largest series of gracilis muscle interposition for treatment of RVFs.

33.* Fürst A, Schmidbauer C, Swol-Ben J, Iesalnieks I, Schwandner O, Agha A. Gracilis

transposition for repair of recurrent anovaginal and rectovaginal fistulas in Crohn's

disease. Int J Colorectal Dis. 2008;23(4):349-53.

* Largest series of gracilis muscle interposition for treatment of RVFs in

Crohn’spatients.

34. Ulrich D, Roos J, Jakse G, Pallua N. Gracilis muscle interposition for the treatment of

recto-urethral and rectovaginal fistulas: a retrospective analysis of 35 cases. J

PlastReconstrAesthet Surg. 2009;62(3):352-6.

35. Lefèvre JH, Bretagnol F, Maggiori L, Alves A, Ferron M, Panis Y. Operative results and

quality of life after gracilis muscle transposition for recurrent rectovaginal fistula. Dis

Colon Rectum. 2009;52(7):1290-5

36. Maeda Y, Heyckendorff-Diebold T, Tei TM, Lundby L, Buntzen S. Gracilis muscle

transposition for complex fistula and persistent nonhealing sinus in perianal Crohn's

disease. Inflamm Bowel Dis. 2011;17(2):583-9.

37. Van der Hagen SJ, Soeters PB, Baeten CG, van Gemert WG. Laparoscopic fistula

excision and omentoplasty for high rectovaginal fistulas: a prospective study of 40

patients. Int J Colorectal Dis. 2011;26(11):1463-7.

38. Cooke SA, Wellsted MD. The radiation-damaged rectum: resection with coloanal

anastomosis using the endoanal technique. World J Surg. 1986;10(2):220-7.

39. Schouten WR1, Oom DM. Rectal sleeve advancement for the treatment of persistent

rectovaginal fistulas. Tech Coloproctol. 2009;13(4):289-94.


40.* Sands BE, Blank MA, Patel K, van Deventer SJ; ACCENT II Study. Long-term treatment

of rectovaginal fistulas in Crohn's disease: response to infliximab in the ACCENT II

Study. ClinGastroenterolHepatol. 2004;2(10):912-20.

* Infliximab for treatment of RVFs in Crohn’s patients.

41. Faucheron JL, Saint-Marc O, Guibert L, Parc R. Long-term seton drainage for high anal

fistulas in Crohn’s disease- a sphincter-saving operation? Dis Colon Rectum 1996; 39:

208-211.

42. Thornton M, Solomon MJ. Long-term indwelling seton for complex anal fistulas in

Crohn’s disease. Dis Colon Rectum 2005;48:459-463.

43. Valente MA, Hull TL. Contemporary surgical management of rectovaginal fistula in

Crohn's disease. World J GastrointestPathophysiol. 2014;5(4):487-95.

44. Lowry AC, Thorson AG, Rothenberger DA, Goldberg SM. Repair of simple rectovaginal

fistulas. Influence of previous repairs. Dis Colon Rectum. 1988;31(9):676-8.

45. Halverson AL, Hull TL, Fazio VW, Church J, Hammel J, Floruta C. Repair of recurrent

rectovaginal fistulas. Surgery. 2001;130(4):753-7; discussion 757-8.

46. deWeerd L, Weum S, Norderval S. Novel treatment for recalcitrant rectovaginal fistulas:

fat injection.IntUrogynecol J. 2015 Jan;26(1):139-44.

47. García-Olmo D, García-Arranz M, García LG, Cuellar ES, Blanco IF, Prianes LA, Montes

JA, Pinto FL, Marcos DH, García-Sancho L. Autologous stem cell transplantation for

treatment of rectovaginal fistula in perianal Crohn's disease: a new cell-based therapy.Int

J Colorectal Dis. 2003 Sep;18(5):451-4.

48. García-Arranz M, Dolores Herreros M, González-Gómez C, de la Quintana P,

Guadalajara H, Georgiev-Hristov T, Trébol J, Garcia-Olmo D.Treatment of Crohn's-


Related Rectovaginal Fistula With Allogeneic Expanded-Adipose Derived Stem Cells: A

Phase I-IIa Clinical Trial.Stem Cells Transl Med. 2016 Jul 13. pii: sctm.2015-0356.

49. Lamazza A, Fiori E, Schillaci A, Sterpetti AV, Lezoche E.Recurrent rectovaginal fistula:

treatment with self-expanding metal stents.Endoscopy. 2015;47Suppl 1 UCTN:E149-50.

50. Lamazza A, Fiori E, Schillaci A, Sterpetti AV, Lezoche E.Treatment of rectovaginal

fistula after colorectal resection with endoscopic stenting: long-term results.Colorectal

Dis. 2015 Apr;17(4):356-60.

51. Wexner, S. D., & Fleshman, J. (2012). Colon and rectal surgery: anorectal operations.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.


Table 1. Outcomes for endorectal advancement flap for rectovaginal fistulas.

Author Year Total Etiology Crohn’s(%) Follow- Overall Crohn’s

(reference) number up Success success

(months) rate (%) rate (%)

Jones et al 1987 23 Crohn’s, 43 25 80 60

(23) Traumatic,

Malignancy

Kodner et al 1993 71 Cryptoglandular, 34 7 93 33

(21) Crohn’s,

Traumatic

Joo et al (24) 1998 20 Crohn’s 100 17 75 75

Sonoda et al 2002 37 All --- 17 43 41

(20)

Pinto et al 2010 75 All 51 16.3 56 44

(22)

Jarrar and 2011 15 Crohn’s, 80 84 87 83

Church (19) cryptoglandular

RVF=rectovaginal fistula
Table 2. Outcomes for gracilis muscle interposition for rectovaginal fistulas.

Author Year Total Crohn’s Overall Crohn’s success rate

number (%) Success (%)

rate (%)

Wexner et 2008 17 53 53 33

al (32)

Furst et al 2008 12 100 92 92

(33)

Ulrich et al 2009 9 78 94 71

(34)

Lefevre et 2009 8 62 75 80

al (35)

Pinto et al 2010 24 25 79 66

(22)

Maeda et 2011 8 100 64 64

al(36)

RVF=rectovaginal fistula
Algorithm 1.

1. Evaluation of a patient with a rectovaginal fistula should include through examination of the

rectum and vagina to carefully assess for fistula location, size, associated pathologies and

underlying diseases. MRI and EUS are the most useful imaging modalities.

2. If sphincter involvement is demonstrated, we elect to initially perform an overlapping repair

with an advancement flap.

3. If no sphincter involvement is demonstrated, transrectal or transvaginal advancement flap

may be performed. Alternatively, it is possible to attempt fistula plug repair, a LIFT procedure or

injection of fibrin glue.


4. A repeat attempt for advancement flap repair may be performed in case of failure.

5. After repeated failure of treatment options mentioned above, we usually recommend

diversion and repeat the advancement flap after diversion.

6. In case of failure, repair of the rectovaginal fistula using gracilis muscle interposition may be

performed.

7. In most cases, the repair should be successful. However, failure may be treated with an

additional advancement flap, or a contralateral gracilis muscle interposition.

8. Failure at this stage may warrant a transabsominal repair or keep the patient with permanent

stoma.

9. An acute rectovaginal fistula should be repaired via overlapping sphinctroplasty with repair of

the overlying rectal and vaginal mucosa.


Legend of Figures

Figure 1. Probe shown being passed through the rectovaginal fistula tract. The incision for LIFT

procedure is undertaken in the intersphincteric groove. Figure reproduced from Wexner, S. D.

and Fleshman J. W. Colon and rectal surgery: anorectal operations, Wolters Kluwer Health,

2011 (51).
Figure 2. Fistula tract is identified and isolated. Figure reproduced from Wexner, S. D. and

Fleshman J. W. Colon and rectal surgery: anorectal operations, Wolters Kluwer Health, 2011

(51).
Figure 3. Fistula tract is divided on both sides between sutures. Figure reproduced from

Wexner, S. D. and Fleshman J. W. Colon and rectal surgery: anorectal operations, Wolters

Kluwer Health, 2011 (51).


Figure 4. Bioprosthetic material may be inserted to separate ends of divided tract. Copyright

Wolters Kluwer 2011. Figure reproduced from Wexner, S. D. and Fleshman J. W. Colon and

rectal surgery: anorectal operations, Wolters Kluwer Health, 2011 (51).


Figure 5. A probe demonstrates the rectovaginal fistula tract. An outline of the endorectal

advancement flap with adequate width is shown. Figure reproduced from Wexner, S. D. and

Fleshman J. W. Colon and rectal surgery: anorectal operations, Wolters Kluwer Health, 2011

(51).
Figure 6. A flap of of mucosa, submucosa, and the circular muscle layer is raised. Of mucosa,

submucosa, and the circular muscle layer. Figure reproduced from Wexner, S. D. and Fleshman

J. W. Colon and rectal surgery: anorectal operations, Wolters Kluwer Health, 2011 (51).
Figure 7. Adequate mobilization of the flap is necessary to avoid tension. Figure reproduced

from Wexner, S. D. and Fleshman J. W. Colon and rectal surgery: anorectal operations, Wolters

Kluwer Health, 2011 (51).


Figure 8. Approximation of the lateral edges of the muscular layer over the fistula opening as an

additional layer of reinforcement. Figure reproduced from Wexner, S. D. and Fleshman J. W.

Colon and rectal surgery: anorectal operations, Wolters Kluwer Health, 2011 (51).
Figure 9. Flap sutured in place. Copyright Wolters Kluwer 2011. Reused with permission. (51)
Figure 10. Rectovaginal fistula plug sutured in place. Figure reproduced from Wexner, S. D. and

Fleshman J. W. Colon and rectal surgery: anorectal operations, Wolters Kluwer Health, 2011

(51).

Das könnte Ihnen auch gefallen