Mini-invasive treatment of rectovaginal fistula

Background: Rectovaginal fistulas (RVFs) are a rare surgical condition. Obstetric injury is the most common cause. Other more frequent causes are cryptoglandular disease, inflammatory bowel disease, pelvic radiotherapy, and colorectal surgery related to partial healing of colorectal anastomosis or previous abscess. Spontaneous healing is extremely rare. Such healing also rarely occurs after stoma. Their treatment is extremely difficult, and no standard surgical technique is accepted worldwide. Various surgical and nonsurgical methods of repair are used, and a gold standard procedure still is to be determined. The surgical approaches reported for the treatment of high RVF are transanal, transvaginal, perineal, transabdominal, and laparoscopic techniques of repair. This report describes a new approach using Transanal Endoscopic Microsurgery (TEM) to treat RVFs. Methods: A retrospective review of 13 patients (median age, 44 years; range, 25–70) who underwent repair of rectovaginal fistula using TEM between 2001 and 2008 was undertaken. In nine cases, RVFs were first treated elsewhere with transperineal direct suture of the rectal and vaginal walls, and four patients had two or three previous attempts at surgical repair with the transabdominal or transperineal approach or both and direct suture. All the patients had a diverting stoma at the first referral. Fistulas occurred as a consequence of transvaginal hysterectomy (n = 7), low anterior mechanical resection (n = 5), and postradiotherapy (n = 1). The surgical technique is widely described. The use of TEM follows the same principles as traditional surgery, with the well-known advantages related to magnification of the view and excellent lightning. The patient is placed in prone position on the operating table. Results: The median follow-up period was 25 months, and the median age of the patients was 44 years (range, 25-70 years). The mean operative time was 130 min (range, 90-150 min), and the hospital stay was 5 days (range, 3-8 days). One patient experienced recurrence. This patient underwent reoperation with TEM and experienced re-recurrence. Two patients had minor complications (hematoma of the septum and abscess of the septum), which were treated with medical therapy. For two patients, a moderate sphincter hypotonia was registered. Discussion and Conclusions: A new technique for treating RVFs using TEM is presented. The authors strongly recommend this approach that avoids any incision of the perineal area, which is very painful and can damage sphincter functions.