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194
E. R. Raskin
of iniximab therapy was found in patients with
Crohn’s disease [32]. While patients with perianal and enterocutaneous stulae had complete
response rates of 78% and 38%, respectively,
RVFs completely healed in only 14% of patients
after 6weeks.
To investigate the longer-term results of
iniximab in patients responding to induction
therapy, a post-hoc analysis of patients with RVFs
participating in the ACCENT II trial (A Crohn’s
Disease Clinical Trial Evaluating Iniximab in a
New Long-term Treatment Regimen in Patients
with Fistulizing Crohn’s Disease) was performed [33, 34]. Patients who were considered
“responders” after 10–14 weeks of iniximab
therapy were randomized to receive iniximab
5mg/kg or placebo every 8weeks through week
54. From weeks 14–46, stula closure rates in
patients receiving iniximab maintenance ranged
from 54.5–90%, compared to 28.6–42.9% in the
placebo maintenance arm. Median duration of
response in the iniximab maintenance group
was 46weeks, in contrast to 33weeks for the placebo maintenance group. However, at week 54,
only 44.4 and 42.9% of stulae remained closed
in the two groups.
Surgical Management
Simple Fistula Repair
Surgical options for repair of a simple RVF can
be predicated by the presence or absence of an
associated sphincter injury. When no evidence
of sphincter injury is noted, repair options range
from endorectal advancement ap (ERAF) to biologic graft repair, depending on the etiology of the
RVF.Unfortunately, simple suture repair seems to
have relatively poor rates of healing, likely due
to the signicant pressure differential between the
rectum and the vagina. This is especially true in
the setting of a thin and poorly vascularized rectovaginal septum. Lay-open stulotomy is only a
valid surgical option in the very distal RVF where
minimal sphincter muscle is involved.
In the presence of a sphincter injury, sphincteroplasty or perineoproctotomy can be considered to address both the RVF and the concomitant
sphincter defect.
Endorectal Advancement Flap
Endorectal advancement ap (ERAF) is the most
commonly performed repair for simple RVF. It
entails the raising of a ap comprised of mucosa,
submucosa, and a portion of internal sphincter
muscle and advancing the tissue down the anal
canal to cover the RVF opening (Fig. 11.1). To
maintain appropriate vascular supply and prevent
necrosis, the ERAF should begin above the stula
opening by 4 cm and have a base that measures
twice the width of the apex. The ap should overlap
the internal opening by 2cm and be tacked in place
with absorbable suture. Alternatively an elliptical
ap can be employed such that only one single distal suture line rather than a distal and two lateral
suture lines are needed. As noted in Chap. 10, it is
the preference of one of the editors (SDW) to utilize an elliptical ap as illustrated in Fig. 10.15a–g.
Case series of ERAF repair report success
rates ranging from 59.6–88% following initial
repair [35–38]. Risk factors for poor healing and
failure of the ERAF include Crohn’s disease, history of pelvic radiation, and prior RVF repair.
Lowry et al. retrospectively evaluated 81
patients who underwent ERAF repair for simple
RVF [38]. Successful repair was noted in 83% of
patients with a strong correlation of success with
the number of prior attempted repairs. The patients
with no prior repair history demonstrated complete
RVF healing rates of 88%, while patients with a
history of a single previous repair showed healing
rates of 85%. In contrast, patients with two prior
attempted repairs healed only 55% of the time.
Biologic Repairs
Fibrin glue tract instillation has been associated
with notoriously poor healing rates (14–33%)
in both anorectal and RVF, and has largely been
abandoned as a rst-line treatment option [39, 40].
Porcine collagen plugs have also been used for
repair of complex stulae, including RVF. Only
small series evaluating plug repair for RVF and
ileoanal pouch vaginal stulae exist, demonstrating
relatively unfavorable results (healing rates 0–60%)
[41–43]. Failure of plug repair has been associated
with dislodgement of the plug, occurring more frequently in the setting of a thinned perineum. While
success rates are unimpressive, the morbidity of the
procedure is low, suggesting that there is a role for
this repair in a subset of patients.
bc
Probe in Recto-
11 Rectovaginal Fistula
vaginal Fistula
a
Flap mucosa
Internal
Sphincter
Internal
Sphincter
Approximated
195
Rectal
Mucosa
Elevated
Attenuated
Perineal Body
Internal
Sphincer
Mobilized
d
Fig. 11.1 Endorectal advancement ap. (a) Probe is
placed through stula. (b) Endorectral ap containing
internal sphincter muscle is elevated. (c) rectal mucosa
Overlapping Sphincteroplasty (OS)
First described by Parks and McPartlin in 1971,
the technique for overlapping sphincteroplasty
has changed only subtly over the past 45 years.
The goals of the procedure are to reconstruct the
entire length of the anal canal by reapproximating the severed ends of the sphincter muscle and
to reestablish a functional sphincter mechanism. In
the setting of RVF, the stula is eradicated as the
sphincter muscles are isolated and then overlapped.
The procedure should be done in the prone
jackknife position with the buttocks taped apart
for optimal exposure. A urinary catheter is placed
for bladder decompression. Typically, a mechanical bowel preparation is recommended with preoperative broad-spectrum antibiotics.
A curvilinear incision is made in the perineum
between the anus and vagina, taking care to
respect the path of the external sphincter. The
dissection is carried through the incision, freeing scar and muscle from both the vagina and
the rectum. The proximal extent of dissection
is the anorectal ring, while the lateral extent is
the perirectal fat. Digital palpation and retraction
e
and internal sphincter muscle is mobilized. (d) internal
sphincter muscle approximated. (e) distal end of ap is
excised, advanced, and sutured in place
through the vagina can help prevent “buttonholing” the posterior wall of the vagina.
Longitudinally, the scar-muscle complex is
transected, creating two separate ends consisting of fused scar with both internal and external
sphincter muscle. At this junction, the RVF is
also divided. The sphincter complex is then recreated by overlapping the muscle ends, tacking
them together with two to three 2-0 absorbable
monolament mattress sutures. Alternatively the
intersphincteric plane can be entered to allow separate imbrication of the internal and overlap of the
external anal sphincters. In the setting of a thinned
perineal body, a concomitant levatorplasty can be
performed to provide additional bulking to the
perineum. Finally, the incision is closed in a longitudinal fashion using absorbable sutures, leaving a ¼-inch Penrose catheter within the wound
to facilitate drainage. Another option is to leave
the central portion of the wound open for drainage
and subsequent healing by secondary intent.
Success of OS in the setting of RVF is measured by closure of the stula tract and postoperative continence. In a small series by Chew
196
Anal Cana
E. R. Raskin
et al., RVF closure rate of 86% with improved
continence scores following OS was reported
after 24 months [44]. Multiple studies have
looked at functional outcomes of OS following
obstetrical injury, reporting “excellent/good”
results in 23–88% of patients after a mean follow up of 24–120months [45–48]. In a study by
Barisic and colleagues, outcomes following OS
were postoperatively evaluated at 3 months and
a mean of 80months using the Cleveland Clinic
Florida-Fecal Incontinence Score (CCF-FIS) for
measurement of continence [47]. While preoperative scores signicantly dropped following
OS, subsequent deterioration of continence was
noted over time. Three months following surgery,
greater than 66% of patients reported satisfactory
results; only 50% of patients reported satisfactory
results after a mean of 80months. It is unclear
what contributes to poor functional results and
decreased continence over time, although patient
age, preoperative pudendal nerve injury, and
early postoperative incontinence have been postulated as contributing factors [48–50].
Perineoproctotomy (PP)
Also referred to as an episioproctotomy, PP is
most commonly utilized for RVF repair in the
setting of a signicant anterior sphincter muscle
defect. First, the stula is identied with a probe
and the residual perineal tissue is divided, essentially resulting in an iatrogenic cloaca. Next,
the sphincter muscles are dissected free from
the edges of the rectovaginal septum. The rectal
mucosa is reapproximated prior to performing an
OS.Lastly, the vaginal mucosa is closed, as well
as, the perineal skin (Fig.11.2).
Historically, surgeons have been reluctant to
perform PP due to concerns of dividing perineal tissue and, occasionally, anterior sphincter
muscle. In a series of 50 patients undergoing PP,
Hull and colleagues demonstrated promising
results with healing rates of 78%, comparable
ac
Fistulous Tract
Vaginal Mucosa
l
Fig. 11.2 Perineoproctotomy. (a) Fistula tract is opened
from vagina to anus. (b) Rectal mucosa is approximated.
(c) Internal sphincter muscle is approximated. (d) External
b
Rectal
Mucosa
Approximated
Internal
Sphincter
Approximated
Vaginal Mucosa,
Perineal Body,
External Sphincter
Approximated
in Layers
sphincter, perineal body, and vagina mucosa are approximated in layers
d
11 Rectovaginal Fistula
197
to prior studies [51–53]. Improved fecal continence scores and sexual function have also been
reported following PP repair [51].
Complex Fistula Repair
Tissue interposition aps or reoperative resections
can be warranted for complex RVF that may be
large in size, surrounded by brotic tissue, recurrent in nature or associated with Crohn’s disease.
Bulbocavernosus Muscle Flap
First described by Heinrich Martius in 1928, the
Martius ap is a pedicled ap that consists of
bulbocavernosus muscle and broadipose tissue
from the labia majorus. It has been used for repair
of urogynecologic defects and RVF. Drawing
its blood supply from the internal and external pudendal arteries, it is a well-vascularized,
accessible, and mobile ap that is well-suited for
repairing complex and recurrent RVF, typically
located in the lower to middle-third of the vagina.
After dissecting out the stula in the rectovaginal septum through a perineal approach, both
the rectal and vaginal stula openings are sutured
closed. The ap is harvested through a longitudinal incision in the labia majorus, taking care to
preserve the integrity of the posterolateral internal
pudendal artery. Sufcient ap length should be
achieved to allow for tunneling of the ap underneath the bulbospongiosus muscle and tacking of
the apex of the ap 2cm proximal to the stula
tract (Figs.11.3, and 11.4).
Although only reported in small series, success rates of 65–100% have been noted, with
acceptable quality of life, sexual satisfaction, and
continence scores [54–56].
Harvested through longitudinal incisions in the
medial thigh, the GMTF is obtained by releasing
the gracilis muscle tendon from its tibial insertion,
ligating collateral vessels, and rotating the muscle
over its neurovascular pedicle (Fig. 11.7). The
GMTF is brought through a subcutaneous tunnel
to the perineum and then positioned between the
rectum and vagina, overlapping the stula tract by
at least 2cm (Fig. 11.8). A diagram of the procedure is presented in Fig.11.9a, b. Alternatively
the gracilis muscle can be harvested through 2
3-4cm long incisions, one overlying the proximal
neurovascular pedicle and one overlying the distal
tendon (Figs. 11.10, 11.11, and 11.12).
Gracilis Muscle Transposition Flap (GMTF)
Typically reserved for recurrent RVF, the gracilis
muscle transposition ap has also been utilized
for primary repair in patients with high risk for
repair failure such as a history of prior pelvic
irradiation, Crohn’s disease, large stulae, or
poor vascular supply to perineum. The rectovaginal septum is opened (Fig.11.5) until the stula
is identied (Fig.11.6).
Fig. 11.3 Martius ap. Courtesy of Dr. Sam Siddighi
198
ab
t
E. R. Raskin
Mobilization of
Bulbocavernosus M.
and Labial Fat
Subcutaneous
Tunnel for Graf
Rectal Layer
Closed
Fig. 11.4 Martius Flap. (a) Bubocavernous muscle and
fat pad are mobilized through incison lateral to labia.
Inferior blood supply is maintained. A pocket is created
between vaginal mucosa and stula. Rectal muscle at s-
Pedicle Graft over
Rectal Closure
tula site is approximated through vaginal mucosa incision.
(b) A subcutaneous tunnel is created from labial incision
to vaginal pocket. Pedicle of graft is positioned over rectal
muscle and sutured in place. Incisions are closed
Fig. 11.5 Operative photograph demonstrating open
rectovaginal stula
Fig. 11.6 Identication of stula
The gracilis muscle may be harvested with
the patient in the modied lithotomy position but
secured in place after delineation of the stula
and dissection of the rectovaginal septum to the
level of the anterior peritoneal reection in the
prone jackknife position. The patient should be
mainted in an adduction splint for 3 days after
surgery. Closed suction drains are left in both
the thigh and perineal wounds until hospital discharge [57–59].
Fig. 11.7 Gracilis muscle is harvested. Courtesy of Dr.
Izabela Galdyn
tunnel for graft
11 Rectovaginal Fistula
199
a
Gracilis
muscle
Rectal layer
closed
b
Fig. 11.8 Gracilis muscle has been brought through a
subcutaneous tunnel to the perineal wound. Courtesy of
Dr. Izabela Galdyn
Healing rates of 53–92% have been noted in
small series, with reports of minor complications such as wound infection, vaginal bleeding, and dyspareunia [60–62]. Fecal diversion
is recommended due to the complexity of the
stulae and the degree of dissection. Successful
stoma closure has been reported in up to 80%
of patients.
Transperineal Omental Flap (TPOF)
Transperineal omental ap has also been
employed for RVF repair by mobilizing the
omentum from the hepatic exure to the greater
curvature of the stomach and, then buttressing
the rectovaginal septal space with the well-vascularized omentum [63]. In addition, a perineal
incision is used to further dissect out the RVF
and to help anchor the omentum below the tract.
Schloericke etal. reported a 100% healing rate
in a series of nine patients within a 22-month
follow up period. Studies by van der Hagen
Subcutaneous
Fig. 11.9 (a, b) Gracilis muscle transposition ap
Fig. 11.10 One of the editors (SDW) prefers 2 smaller
leg incisions instead of 1 long leg incision. The arrow
shows the expected position of the neurovascular
pedicle
et al. and Mukwege et al. demonstrated successful techniques paring laparoscopic stula
excision and omentoplasty for high RVF [64,
65]. Created laparoscopically, the TPOF has
the advantages of minimizing operative trauma
200
E. R. Raskin
Fig. 11.11 Proximal muscle and neurovascular pedicle
Fig. 11.12 With the patient in the prone-jackknife posi-
tion, the muscle has been delivered through the perineal
incision and will be secured in place between the anterior
(vaginal) and posterior (rectal) stula openings. Both the
vaginal and rectal openings have been repaired by excision and primary ap closure and the sutures with which
the gracilis muscle will be parachuted into place have
been placed and tagged
and avoiding the physiologic impact of muscle
transposition.
Resection Repair
In the setting of persistent RVF after proctectomy or previous repair, colorectal resection
may be warranted. Reoperative surgery with a
new colorectal or coloanal anastomosis may
be an option, typically employing a proximal
diverting stoma.
Originally described in the setting of
Hirschsprung’s disease, Chagasic megacolon,
and rectal cancer, the Turnbull-Cutait delayed
coloanal anastomosis has also been utilized in the
Fig. 11.13 Turnbull-Cutait coloanal anastomosis
setting of RVF to preserve sphincter function and
salvage intestinal continuity (Fig. 11.13). This
procedure involves a colonic pull-through with
exteriorization of the proximal colon, followed by
delayed coloanal anastomosis several days later.
Although results from this approach have
been promising with stoma-free RVF closure
rates around 80%, the procedure is associated
with high postoperative morbidity (19–55%) [66,
67]. Based on the difculty of reoperative pelvic
surgery and elevated surgical risks, reoperative
surgery with or without delayed coloanal anastomosis is only recommended after all conservative
repair options have been exhausted.
Bricker Patch Repair
In the setting of a radiation-induced stula associated with stricture of the rectum, a Bricker
patch or onlay colonic patch technique can be
utilized (Fig. 11.14). The procedure involves
dissecting out the RVF with stulectomy. The
vaginal stula opening is closed, while the rectal defect is patched with a portion of proximal colon. This allows for a widening of the
affected stretch of rectum and restoration of
function [68].
Stent Repair
Lamazza and colleagues have described the use
of endoscopically placed, self-expanding metallic stents in the setting of RVF after colorectal
cancer resection [69]. In a small series of ten
patients, an 80% healed rate without signicant
fecal incontinence was noted after a mean follow
ab
11 Rectovaginal Fistula
Fig. 11.14 Bricker patch repair. (a) Sigmoid colon is
divided and distal end spatulated. (b) sigmoid is anastomosed to stula and proximal sigmoid is attached to top of
bowel loop
201
patients and was adversely affected by steroid
use and smoking.
Multiple authors have demonstrated similar
long-term results ranging from 50–56% healing
rates [37, 71–73]. An average of 2.1 procedures
per patient was noted by Lofer to achieve healing, with 20% of patients ultimately undergoing
proctectomy.
Disease activity, integrity of the perineal body,
and quality of the sphincter complex should be
taken into consideration prior to repair. As the
presence of RVF is a negative prognostic indicator
for successful anti-TNF-α therapy, active proctitis
is negative prognostic indicator for surgical repair.
Ileoanal Pouch–Vaginal Fistula (IPVF) Repair
IPVF can occur following pouch creation as
a result of poor healing or the development of
Crohn’s disease. In the setting of non-Crohn’s
related RVF, ileal advancement ap, re-do pouch
surgery, and pouch excision have been advocated
[74]. With Crohn’s-related RVF, biologic therapy
is typically initiated with hopes of minimizing
active disease and salvaging the pouch. Poor
response to biologic therapy is associated with
increase pouch failure rate.
up of 24months. The two patients who did not
completely heal after stenting had reduction in
stula diameter, allowing for successful closure
with an advancement ap.
Crohn’s-Related RVF Repair
RVF in the setting of Crohn’s disease is notoriously difcult to treat both medically and surgically. As evidenced by the ACCENT II trial,
iniximab responders with RVF only remained
healed at 54 weeks in 44% of cases. Multiple
surgical approaches (ranging from ERAF to
coloanal pull-through to proctectomy) have been
taken to eradicate RVF, as there is no consensus
regarding the appropriate strategy for this heterogeneous subset of patients.
El-Gazzaz and colleagues used ERAF, PP,
coloanal pull-through, and biologic grafts and
found no signicant difference in the type of
repair between healed and unhealed patients
[70]. Successful healing was noted in 46.2% of
Diversion
Controversy remains regarding whether a patient
undergoing RVF repair requires fecal diversion.
While stomas tend to be created in the setting of
more complex stulae and in patients with multiple comorbidities, studies have suggested that
diversion has no inuence on recurrence, complication rates, wound infections, or number of
operative revisions [75]. Most of the data regarding diversion in this setting emanate from retrospective studies where surgeons have elected to
divert for various reasons. No randomized trials
have been conducted to address this question.
Conclusion
A distressing condition aficting millions of
women worldwide, RVF is a complex condition that has traumatic, neoplastic, infectious,
and inammatory origins. A careful eye and
202
E. R. Raskin
high index of suspicion must be utilized for
accurate evaluation of the female patient who
presents with the symptoms of the passage of
gas and/or stool through the vagina. No clear
consensus exists for management of RVF, as
great heterogeneity exists amongst women
seeking treatment. From the simple lay-open
stulotomy to more complex tissue interposi-
tion grafts, multiple surgical procedures have
been utilized with varied results. ERAF are
utilized with the greatest frequency for simple
RVF with success rates in the 60–88% range.
Complex stulae tend to require more aggres-
sive surgical intervention, commonly warrant-
ing more than one attempt at repair. In the
setting of Crohn’s disease, the presence of
active disease can eliminate particular surgical
options and inhibit appropriate wound heal-
ing. A careful evaluation of each patient with
RVF is necessary to tailor treat-
ment for appropriate medical and surgical
intervention.
Acknowledgements Proctor and lecturer for Intuitive
Surgical, Inc.
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