Rectovaginal Fistulas

Abstract

To describe the etiology, anatomy and pathophysiology of rectovaginal fistulas (RVFs); and to describe a systematic surgical approach to help achieve optimal outcomes. A current review of the literature was performed to identify the most up-to-date techniques and outcomes for repair of RVFs. RVFs present a difficult problem that is frustrating for patients and surgeons alike. Multiple trips to the operating room are generally needed to resolve the fistula, and the recurrence rate approaches40% when considering all of the surgical options. At present, surgical options range from collagen plugs and endorectal advancement flaps to sphincter repairs or resection with colo-anal reconstruction. There are general principles that will allow the best chance for resolution of the fistula with the least morbidity to the patient. These principles include: resolving the sepsis, identifying the anatomy, starting with least invasive surgical options, and interposing healthy tissue for complex or recurrent fistulas.

Core tip: There are general principles that will allow the best chance for resolution of a rectovaginal fistula with the least morbidity to the patient. Identifying and addressing the disease process that caused the fistula is critical, including medical management for Crohn’s, and resolving inflammation or sepsis with a seton. Then the exact anatomy of the fistula should be defined to determine operative approaches. The operative algorithm should begin with fistula plugs and local advancement flaps, if these fail more invasive options such as diversion, and interposition of healthy tissue should be pursued for complex and recurrent fistulas.