Inaseparatepublication,thesamegroupreportedonrectovaginal fistularepairinpatientsspecificallywithCrohn’sdisease.Thecohort includedpatientsundergoingeithertransvaginalbiologicmeshinsertion, orbiologicfistulapluginsertion.Inthemeshgroup,fistulassuccessfully healedin4of6(66%)patients.

Itisdifficulttoascertaintheutilityandimpactofbioprostheticmesh ontheoutcomesoftransvaginalapproachtorectovaginalfistularepair, giventhedifferencesintechniquesandheterogeneityofthecaseseries publishedtodate.Thevariabilityofoutcomesofsurgeryforrectovaginal fistulaingeneralmakesthepotentialbenefitofrepairaugmentationwith interpositionmeshcompellingandworthyoffurtherinterestand continuedstudytodeterminetheindicationsforitspotentialuseand safetyforthisindication.Thistechniquehasyettobestudiedadequately, butthisisnotuniquetotheliteratureingeneralregardingthetopicof surgeryforrectovaginalfistula.Overall,thecurrentstatusofthe literatureformanagementofrectovaginalfistulasremainswantingasthe heterogeneityofthecondition,variationinanatomicaldefects,multitude ofcauses,andthenumerousdescribedtechniquesforrepairmakethis topicespeciallychallengingtoinvestigate.Itisarguablethatfew conditionsareingreaterneedforwell-designed,multi-institutional prospectivestudiestoprovidebetterevidenceonwhichtobaseour treatmenttoalleviatethesufferingofthisgroupofpatients.

Despitemanysurgicaloptions,managementofrectovaginalfistula(RVF) stillremainsasurgicalchallengewithahighfailurerate,whateverthe surgicaloptionchosen.

ThischapterdescribesthetreatmentofRVFbytransvaginalapproach withoutamesh.Althoughthistechniqueisnotthemostusedinthis indication,itcanbeproposedasaconservativeprocedure,asan alternativetotransanalapproach,beforemoreaggressiveoperations suchastemporarystomaandgraciloplastyareundertaken.

Thus,thetransvaginalapproachwithoutameshcanbeproposedin symptomaticpatientsforwhomaminorlocaltreatmentisdiscussed.In ourexperience,aswellasinmanyothercenters,this“minor”local

treatmentcanbeeitherthroughatransvaginalapproachwithoutmeshor throughanalternativesuchastransanalflaprepair.Ifitfails,the authors’policyistoproposeasecondstepwithsimilarminorlocal treatmentbutassociatedwithatemporarystoma.Ifthisrepeatattempt withdiversionfails,amoreaggressiveproceduresuchasatransperineal approachwithgracilismuscleorMartiusflapinterpositionisdiscussed.

bestoption HighRVFforwhichanabdominalapproachforrepairisthebestoption.

Afterclinicalexamination,confirmingtheexistenceofanRVFlocatedon thelowerpartofthevaginaandtherectum,forwhichatransvaginal repairispossibleandindicated,preoperativeassessmentwithendoscopy and/orimagingdependsontheetiologyoftheRVF.

Thepatientsreceivemechanicalbowelpreparationthedaybefore operationwithanadditionalprophylacticenemarepeatedonthe morningoftheoperation.

DirectRVFclosure Vaginaladvancementflap