# Sphincter repair procedures may be favored in the treatment of obstetrical recto-vaginal fistula: a systematic review of the literature and meta-analysis

A. Venara, E. Houlet, E. Poupard, M. André, P E Bouet, J. Gillet, J F Hamel

► To cite this version:

A. Venara, E. Houlet, E. Poupard, M. André, P E Bouet, et al., Sphincter repair procedures may be favored in the treatment of obstetrical recto-vaginal fistula: a systematic review of the literature and meta-analysis. Techniques in Coloproctology, 2025, 29 (1), pp.95. 10.1007/s10151-025-03133-3. [hal-05233269](https://hal.science/hal-05233269v1)

HAL Id: hal-05233269

https://hal.science/hal-05233269v1

Submitted on 1 Sep 2025

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
# Sphincter repair procedures may be favored in the treatment of obstetrical recto-vaginal fistula: a systematic review of the literature and meta-analysis

A. Venara<fnref n="1" />,<fnref n="2" />,<fnref n="3" />,<fnref n="4" />,<fnref n="7" /> · E. Houlet<fnref n="1" />,<fnref n="5" /> · E. Poupard<fnref n="1" /> · M. André<fnref n="1" /> · P. E. Bouet<fnref n="1" />,<fnref n="5" /> · J. Gillet<fnref n="1" />,<fnref n="2" /> · J. F. Hamel<fnref n="1" />,<fnref n="6" />

Received: 31 October 2024 / Accepted: 23 February 2025 / Published online: 7 April 2025

© The Author(s) 2025, corrected publication 2025

## Abstract

**Background** The management of obstetric rectovaginal fistula (RVF) is challenging for the surgeon. The best surgical procedure to repair RVFs, specifically after obstetric anal sphincter injury, has not been extensively studied. The objective was to compare the success of the different procedures performed to repair obstetric RVF.

**Methods** The literature search was carried out on PubMed® and Web of Science® from database inception until 31 December 2022. Selection criteria were: (1) patients with a diagnosis of obstetric-related RVF; (2) patients treated surgically with no restriction concerning the considered surgery; (3) clinical trials or epidemiological studies. Meta-analysis was conducted considering the network meta-analysis framework to allow studying the relative value of each treatment mentioned in the selected articles.

**Results** The quantitative synthesis included 32 studies (18 retrospective and 14 prospective) accounting for 595 patients. The quality of these studies was low because of the lack of prospective randomization. Nineteen procedure types were described and assessed. Most patients (n = 180) underwent endorectal advancement flap (ERAF) followed by excision and layered closure (ELC) (n = 213) and Musset procedure (n = 65). A diverting stoma was performed in 66/132 patients. Only 13 studies reported the functional results of the procedure. In the meta-analysis, the Musset procedure (OR = 4.29; 95% CI: 1.18–16.14), transvaginal ELC (OR = 11.84; 95% CI: 2.18–91.80) and transperineal ELC (OR = 3.56; 95% CI: 1.26–10) significantly improved the anatomical results compared to ERAF.

**Conclusions** A further randomized controlled trial in the literature assessing ERAF and sphincteroplasty to compare the anatomical results, functional results and morbidity of this treatment is needed.

**Registration** PROSPERO CRD42023447875.

**Keywords** Obstetric · Anovaginal fistula · Rectovaginal fistula · Repair

<figure><img src="image_2.png" /></figure>

<footnote>A. Venara and H. Houlet shared first authorship.</footnote>

<footnote>A. Venara
auvenara@chu-angers.fr</footnote>

<footnote n="1">¹ Faculty of Health, Department of Medicine, University of Angers, Angers, France</footnote>

<footnote n="2">² Department of Digestive Surgery, University Hospital of Angers, 4 rue Larrey, Angers Cedex 9, 49933 Angers, France</footnote>

<footnote n="3">³ IHFIH, UPRES, University of Angers, 3859 Angers, EA, France</footnote>

<footnote n="4">⁴ The Enteric Nervous System in Gut and Brain Disorders, Université de Nantes, INSERM, TENS, IMAD, 44000 Nantes, France</footnote>

<footnote n="5">⁵ Department of Gynecology and Obstetrics, University Hospital of Angers, 4 rue Larrey, Angers cedex 9, 49933 Angers, France</footnote>

<footnote n="6">⁶ Department of Biostatistics, La Maison de La Recherche. University Hospital of Angers, 4 rue Larrey, Angers Cedex 9, 49933 Angers, France</footnote>

<footnote n="7">⁷ Department of Visceral Surgery, CHU Angers, 4 rue Larrey, 49933 Angers Cedex 09, 49933 Angers, France</footnote>
# Introduction

Obstetrical genito-urinary and recto-vaginal fistulas (RVFs) are reported to occur in 0 to 4.09 per 1000 births in low- and middle-income countries (LMICs) [1, 2]. In Western countries, RVF complicates 1–3% [3] of anal sphincter injuries (OASI) occurring in 0.5–4.5% of deliveries [4]. The mechanism of RVF may be different in LMICs and Western countries. Indeed, in Western countries, RVF is secondary to OASI or wound dehiscence, and it is carried out because of prolonged labor leading to necrosis of the perineum secondary to crushing by the fetal head in LMICs.

As obstetric RVF is the main cause of RVF, specific guidelines to treat this complication would be expected. However, the management of this RVF is challenging for the surgeon as no guidelines have been published. Current literature lacks studies focusing exclusively on the obstetric etiology of RVFs, while Karp et al. [5] report that non-obstetric RVFs have a nearly fourfold increased risk of repair failure compared with obstetric fistulas. The results of studies not focusing on obstetric causes should therefore be interpreted with caution as the other causes of RVF may impair outcomes of the proper surgical procedure.

In a recent nationwide retrospective cohort, Venara et al. reported that more than ten procedures can be performed to cure RVFs, from low-invasive sphincter-sparing procedures to gracilis flaps and the Musset procedure [6]. In this report, the most performed procedure was the sphincter-sparing endorectal advancement flap (ERAF) procedure [6] in accordance with the American Society of Colon and Rectal Surgeons (ASCRS) recommendations for the treatment of anoperineal fistulas [7]. However, this latter procedure is successful in only 22–50% [6, 8, 9] of cases, which calls for new guidelines for this specific disease.

To develop guidelines, the strongest evidence is needed, and a review of the literature with a meta-analysis may facilitate this. The main aim of this systematic review of the literature and meta-analysis was to compare the success of the different procedures performed to repair obstetric RVF. The secondary aim was to give an overview of the role of the diverting stoma in RVF healing.

# Methods

## Search strategy

The present review and meta-analysis were conducted according to the recommendations of the PRISMA statement for reporting systematic reviews and meta-analyses of studies [10]. It was registered with PROSPERO.

Systematic searches were performed in 2023 in two different databases: PubMed® and Web of Science®. Studies published from database inception to 31 December 2023 in English or French language were considered. A combination of MeSH terms and text words was used: ((rectovaginal) OR (anovaginal) OR (recto-vaginal) OR (ano-vaginal)) AND (fistula) AND (obstetric*). Reference lists of included articles were considered to identify any other trials. Experts were consulted to ensure that all key studies were included.

Studies that met the following criteria were included in the systematic review: (1) patients with a diagnosis of obstetric-related RVF, (2) patients treated surgically with no restrictions concerning the considered surgery and (3) clinical trials or epidemiological studies (prospective observational, cohort, cross-sectional or retrospective).

Studies were excluded if (1) they were case reports, (2) they were not a full-text paper (i.e., exclusion of reviews, protocol publications, abstracts, letters and comments), (3) the study did not report results specifically for the specific obstetric-related subsample for studies focusing on a population of patients including both obstetric-related and non-obstetric-related rectovaginal fistula, (4) the surgical procedure was not described and (5) the study involved animals. No other restriction was used. When the studies were not available, the authors were contacted to request the manuscript.

# Data extraction

All results were screened for duplication by author, title, journal and publication date. Selected articles were screened for relevance in a hierarchical procedure first by title, then abstract and finally by the full text of all studies previously considered relevant. This procedure was conducted independently by two different co-author groups: EP and AM; EH and JG. In case of any discrepancy, a third author (AV) reviewed the article for final assessment.

Data were extracted from the included studies to a standard sheet including the first author, year of publication, study design, number of patients enrolled, number of patients enrolled with a diagnosis of obstetric RVF, success rate of the surgery and type of procedure, functional success of the procedure, construction of a diverting stoma and Joanna Briggs Institute (JBI) critical appraisal tool components. Two co-authors independently collected these data (EH and JG).

The main outcome measure was the success of the surgical procedure defined by the anatomical correction of the defect and the absence of stool and/or gas passing in the vagina. The secondary outcomes were: (1) the functional success of the procedure defined by the absence of
postoperative fecal incontinence and (2) the construction of
a diverting stoma.

Quality assessment

The quality assessment was performed according to the JBI
critical appraisal tool for cohort and case series [11].

Data synthesis and analysis

Only papers mentioning the results of the surgery in terms of anatomical correction of the defect, absence of postoperative fecal incontinence and/or of construction of a diverting stoma were selected for the meta-analysis. Meta-analysis was conducted considering the network meta-analysis framework to facilitate the study of the relative value of each of the treatments mentioned in the selected articles. Arm-based network meta-analyses based on the Zhang et al. Bayesian hierarchical models, suitable for binary outcomes, were

<figure><img src="image_3.png" /></figure>

<caption>Fig. 1 PRISMA flow chart</caption>

<footnote>*Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers).</footnote>

<footnote>**If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools.</footnote>
<table><caption>**Table 1** Characteristics of the different retrospective articles included in the literature review</caption><thead><tr><th>Articles</th><th>Number of patients</th><th>Patient age</th><th>Setting of the study</th><th>Follow-up</th></tr></thead><tbody><tr><td>Venara et al. [6]</td><td>n = 60 patients/n = 148 procedures</td><td>Mean = 36.2 ± 10.6 years</td><td>Multicentric</td><td>12 months (± 18) from the date of the last surgery</td></tr><tr><td>Beksac et al. [13]</td><td>n = 8/19</td><td>Mean = 27.63 ± 7.17 years</td><td>Monocentric</td><td>ND</td></tr><tr><td>Reisenauer et al. [14]</td><td>n = 13/48</td><td>Between 21 and 39 years</td><td>Monocentric</td><td>Between 1 and 10 years, depending on the time when the fistula repair was done</td></tr><tr><td>Hull et al. [9]</td><td>n = 54/87</td><td>ND</td><td>Monocentric</td><td>Mean: 49.2 ± 39.2 months</td></tr><tr><td>Songne et al. 2007 [15]</td><td>n = 1/14</td><td>ND</td><td>Monocentric</td><td>Mean: 40 months (range: 8–120 months)</td></tr><tr><td>Devesa et al. [16]</td><td>n = 4/46</td><td>ND</td><td>Monocentric</td><td>Mean: 8.6 years (range, 2–22 years)</td></tr><tr><td>Chew et al. [17]</td><td>n = 7/7</td><td>Mean: 34 years (range: 22–72)</td><td>Bicentric</td><td>Mean: 24 months (range: 11–35)</td></tr><tr><td>Rhaman et al. [18]</td><td>n = 52/52</td><td>Mean: 29.5 years (range 17–65)</td><td>Monocentric</td><td>Median: 24 months min–max: 6 months to 8 years)</td></tr><tr><td>Sonoda et al. [8]</td><td>n = 5/37</td><td>ND</td><td>Monocentric</td><td>Median: 17.1 months (range: 0.4–66.9)</td></tr><tr><td>Soriano et al. [19]</td><td>n = 25/48</td><td>ND</td><td>Monocentric</td><td>Between 1 and 3 years</td></tr><tr><td>Ozuner et al. [20]</td><td>n = 13/52</td><td>ND</td><td>Monocentric</td><td>Median: 31 months (±21.4)</td></tr><tr><td>MacRae et al. [21]</td><td>n = 14/28</td><td>ND</td><td>Monocentric</td><td>Mean: 11.8 months (range, 2–53)</td></tr><tr><td>Reisenauer et al. [22]</td><td>n = 29/29</td><td>Mean: 29.27 years (range: 21–38)</td><td>Monocentric</td><td>Up to 14 years</td></tr><tr><td>Karp et al. [5]</td><td>n = 53/88</td><td>Median: 37 years (IQR:32.0–47.0)</td><td>Monocentric</td><td>Median: 157.0 days (range, 47.5–402.0)</td></tr><tr><td>Zmora et al. [23]</td><td>n = 1/5</td><td>35 years</td><td>Monocentric</td><td>9 months after the surgery and 1 month after the stoma closure</td></tr><tr><td>Frontall et al. [25]</td><td>n = 10/51</td><td>Mean: 42 years (± 12)</td><td>Bicentric</td><td>Mean: 56 ± 48 months (range 1–183)</td></tr><tr><td>Corman et al. [24]</td><td>n = 28/28</td><td>Mean 36 years (range:20–66)</td><td>Monocentric</td><td>3 months to 3 years</td></tr><tr><th>Articles</th><th>Procedures performed (N performed/N)</th><th>Anatomical success</th><th>Functional results (no anal incontinence)</th><th>Diverting stoma</th><th>Morbidity</th></tr><tr><td>Venara et al. [6]</td><td>ERAF: n = 49/148, gracilis interposition n = 3/148<br>Insertion of glue n = 10/148<br>Ovesco clip n = 9/148<br>Vaginal suture or flap<br>n = 8/148<br>Plug n = 7/148<br>Seton ablation n = 14/148<br>Musset procedure n = 23/148<br>Martuis flap n = 16/148</td><td>n = 11/49<br>n = 2/3<br>n = 4/10<br>n = 3/9<br>n = 3/8<br>n = 3/7<br>n = 4/14<br>n = 15/23<br>n = 8/16</td><td>ND</td><td>n = 29/60 (26 closures)</td><td>ND</td></tr><tr><td>Beksac et al. [13]</td><td>Transperineal ELC + sphincteroplasty: n = 8/8</td><td>n = 8/8</td><td>n = 8/8</td><td>None</td><td>None</td></tr></tbody></table>

<figure><img src="image_4.png" /></figure>
<table><caption>**Table 1 (continued)**</caption><thead><tr><th>Articles</th><th>Procedures performed (N performed/N)</th><th>Anatomical success</th><th>Functional results (no anal incontinence)</th><th>Diverting stoma</th><th>Morbidity</th></tr></thead><tbody><tr><td>Reisenauer et al. [14]</td><td>Transperineal ELC n = 3/13<br>Transvaginal ELC n = 7/13<br>Martius flap n = 1/7<br>Suture of the fourth degree perineal injury n = 1/13</td><td>n = 3/3<br>n = 7/7<br>n = 1/1<br>n = 1/1</td><td>ND</td><td>n = 4/13 (4 closures)</td><td>ND</td></tr><tr><td>Hull et al. [9]</td><td>ERAF n = 18/54<br>Transperineal ELC n = 36/54</td><td>n = 10/18<br>n = 29/36</td><td>ND</td><td>ND</td><td>n = 11/47 (all etiologies)</td></tr><tr><td>Songne et al. 2007 [15]</td><td>Martius flap n = 1</td><td>n = 1/1</td><td>ND</td><td>n = 1/1</td><td>n = 3/14 (all etiologies)</td></tr><tr><td>Devesa et al. [16]</td><td>ERAF n = 2/4<br>Transperineal ELC n = 1/4<br>Rectal and vaginal flap;<br>sphincteroplasty and colostomy; colostomy take-down n = 1/4</td><td>n = 2/2<br>n = 1/1<br>n = 1/1</td><td>ND</td><td>n = 1/4</td><td>None</td></tr><tr><td>Chew et al. [17]</td><td>Transperineal ELC + overlapping sphincteroplasty n = 7/7</td><td>n = 5/6</td><td>n = 4/5</td><td>None</td><td>ND</td></tr><tr><td>Rhaman et al. [18]</td><td>Transvaginal ELC n = 39/52<br>- Musset procedure n = 8/52<br>- Healed spontaneously n = 5/52</td><td>n = 39/39<br>n = 8/8<br>n = 5/5</td><td>n = 44/52</td><td>None</td><td>Urinary infection n = 4 urinary retention n = 2 wound infection n = 3 anal incontinence n = 2</td></tr><tr><td>Sonoda et al. [8]</td><td>ERAF 5/5</td><td>n = 2/5</td><td>ND</td><td>None</td><td>ND</td></tr><tr><td>Soriano et al. [19]</td><td>Musset procedure n = 25/25</td><td>n = 24/25 (after 2 procedures for 2 patients)</td><td>ND</td><td>ND</td><td>n = 2/48 (all etiologies)</td></tr><tr><td>Ozuner et al. [20]</td><td>ERAF n = 13/13</td><td>n = 10/13</td><td>ND</td><td>ND</td><td>ND</td></tr><tr><td>MacRae et al. [21]</td><td>ERAF n = 9/14 ( - transperineal ELC + sphincteroplasty: n = 5/13<br>- Coloanal anastomosis n = 2/14</td><td>n = 4/9<br>n = 5/5<br>n = 2/2</td><td>ND</td><td>ND</td><td>ND</td></tr><tr><td>Reisenauer et al. [22]</td><td>Transvaginal ELC n = 12/29 + sphincteroplasty n = 3/29<br>- LIFT n = 1/29<br>- Musset procedure (with levatorplasty) n = 9/29<br>- Transvaginal ELC + Martius flap interposition n = 2/29<br>- spontaneous recovery n = 2/29</td><td>n = 10/12<br>n = 3/3<br>n = 1/1<br>n = 8/9<br>n = 2/2</td><td>ND</td><td>n = 10/29 (9 closures)</td><td>ND</td></tr></tbody></table>
<table><caption>**Table 1 (continued)**</caption><thead><tr><th>Articles</th><th>Procedures performed (N performed/N)</th><th>Anatomical success</th><th>Functional results (no anal incontinence)</th><th>Diverting stoma</th><th>Morbidity</th></tr></thead><tbody><tr><td>Karp al. [5]</td><td>Transperineal ELC n = 53/53 (22/53 + sphincteroplasty)</td><td>n = 47/53</td><td>ND</td><td>None</td><td>n = 3/6 (wound infections)</td></tr><tr><td>Zmora et al. [23]</td><td>Gracilis flap: n = 1</td><td>n = 1/1</td><td>ND</td><td>n = 1/1 (1 closure)</td><td>None</td></tr><tr><td>Frontall et al. [25]</td><td>Gracilis flap n = 10/10</td><td>n = 7/10</td><td>ND</td><td>n = 10/10</td><td>ND</td></tr><tr><td>Corman et al. [24]</td><td>Transperineal ELC n = 28/28 (levator plication)</td><td>n = 28/28</td><td>n = 28/28</td><td>None</td><td>Small wound sinus under the skin flap (n = 1)</td></tr></tbody></table>

ERAF endorectal advancement flap, ELC excision and layered closure, IQR interquartile range

used for performing both direct and indirect comparisons of treatment effects [12]. Results were presented as absolute percentage of success (depending on the considered endpoint) and odds ratios considering the most commonly used surgery for obstetric-related RVF treatment (i.e., the ERAF procedure) as the reference treatment.

## Results

### Study selection

The flow chart in Fig. 1 depicts the study selection process. A total of 911 studies were identified through PubMed® and World of Science®, of which 211 were removed because of duplication. Another 600 articles were excluded because they did not meet the inclusion criteria. The other reasons reported in the flow chart were used to group the studies for which no abstract was available and those that did not describe the treatment, the procedure used for surgery or the etiology of RVF.

After screening the studies according to the abstracts and titles, 89 were selected, of which 8 were excluded because the manuscript was not available. Finally, 32 studies were included in the review and meta-analysis.

### Systematic review

Among the 32 studies included, 18 were retrospective studies [5, 6, 8, 9, 13–25] and 14 were observational prospective studies [26–40]. The design was multicentric in four studies. The main results of the different studies included are reported in Tables 1 and 2, respectively, for the retrospective and prospective studies.

The number of patients included in each study varied from 1 to 60. Only six studies focused on post-OASI RVF [6, 17, 18, 22, 24, 36]. Finally, 595 women and/or procedures were considered in this review. The mean or median ages were available in 12 studies and were between 18 and 66 years. Only two studies reported body mass index (BMI) [5, 6]. Venara et al. [6] reported a mean BMI of 27 kg/m² (± 5.5), while Karp et al. [5] reported that 26.4% of the patients had a BMI ≥ 30 kg/m².

Among the 595 patients included, the most performed procedure was the ERAF (n = 180) followed by the Musset procedure (n = 65) and transperineal ELC (n = 149). The success rate was reported between 37.5% and 100% depending on the procedure (Table 3).

<figure><img src="image_5.png" /></figure>
<table><caption>**Table 2** Characteristics of the different prospective articles included in the literature review</caption><thead><tr><th>Articles</th><th>Number of patients</th><th>Patients' age</th><th>Setting of the study</th><th>Follow-up</th></tr></thead><tbody><tr><td>Norderval et al. [26]</td><td>n=9/27</td><td>ND</td><td>Bicentric</td><td>Median: 20 months (inter quartile range (IQR) 14–38 mois)</td></tr><tr><td>Mukwege et al. [28]</td><td>n=8/10</td><td>ND</td><td>Monocentric</td><td>Mean: 14.3 months (11–36) (all the etiologies)</td></tr><tr><td>De Weerd et al. [29]</td><td>n=4/6</td><td>Mean: 33.25 years (26–49 years)</td><td>Monocentric</td><td>Mean: 41 months (IR: 4–53)</td></tr><tr><td>Schwandner et al. [30]</td><td>n=2/21</td><td>ND</td><td>Bicentric</td><td>Mean 12 months (range: 3–18)—(all the etiologies)</td></tr><tr><td>Cui et al. [31]</td><td>n=1/9</td><td>27 years</td><td>Monocentric</td><td>12 months</td></tr><tr><td>Oom et al. [32]</td><td>n=11/26</td><td>ND</td><td>Monocentric</td><td>Median: 14 months (range = 3–50)</td></tr><tr><td>Husain et al. [33]</td><td>n=9/37</td><td>ND</td><td>Monocentric</td><td>4 weeks postoperatively</td></tr><tr><td>Bai et al. [34]</td><td>n=3/21</td><td>ND</td><td>Monocentric</td><td>ND</td></tr><tr><td>Zimmerman et al. [35]</td><td>n=9/21</td><td>ND</td><td>Monocentric</td><td>Median: 15 months (range: 4–66)</td></tr><tr><td>Khanduja et al. [36]</td><td>n=20</td><td>Mean: 30 years (range 18–40)</td><td>Monocentric</td><td>Mean: 40 months (range: 5–75)</td></tr><tr><td>Veronikis et al. [37]</td><td>n=22/34</td><td>ND</td><td>Monocentric</td><td>All patients were evaluated postoperatively at 6 weeks, 6 months, 1 year, and yearly thereafter</td></tr><tr><td>Khanduja et al. [38]</td><td>n=27/48</td><td>ND</td><td>Monocentric</td><td>Mean: 16 months (range 6 weeks–5 years)</td></tr><tr><td>Russell and Gallagher [39]</td><td>n=6/32</td><td>ND</td><td>Monocentric</td><td>Mean > 10 years</td></tr><tr><td>Browning et al. [40]</td><td>n=18/390</td><td>ND</td><td>Monocentric</td><td>6 months</td></tr><tr><td>Tong et al. [27]</td><td>n=5/16</td><td>ND</td><td>Monocentric</td><td>Median: 10.2 months (range: 8–36)—All the etiologies</td></tr><tr><th>Articles</th><th>Procedures performed (n performed / n)</th><th>Anatomical success</th><th>Functional results (no anal incontinence)</th><th>Diverting stoma</th><th>Morbidity</th></tr><tr><td>Norderval et al. [26]</td><td>Autologous fat graft injection: n=8/9<br/>n=9/9</td><td>ND</td><td>ND</td><td>ND</td><td>n=1 (all etiologies)</td></tr><tr><td>Mukwege et al. [28]</td><td>- Laparoscopic dissection<br/>rectal and vaginal suture<br/>n=2/8<br/>- Laparoscopic rectal resection<br/>n=1/8<br/>- Laparoscopic dissection<br/>"pull trough" technic<br/>n=5/8</td><td>n=6/8</td><td>None</td><td>None</td><td>None</td></tr><tr><td>De Weerd et al. [29]</td><td>Autologous fat graft injection<br/>n=4/4</td><td>n=4</td><td>ND</td><td>n=3/4</td><td>n=2/6</td></tr><tr><td>Schwandner et al. [30]</td><td>Surgisis mesh: n=2/2<br/>Martius flap n=1</td><td>n=1/2<br/>n=1/1</td><td>ND<br/>n=1</td><td>ND<br/>n=1/1</td><td>n=4/21 (all the etiologies)<br/>Wound swollenness n=3/9 (all the etiologies)</td></tr><tr><td>Cui et al. [31]</td><td></td><td></td><td></td><td></td><td></td></tr></tbody></table>

<figure><img src="image_6.png" /></figure>
<table><caption>**Table 2 (continued)**</caption><thead><tr><th>Articles</th><th>Procedures performed (n performed / n)</th><th>Anatomical success</th><th>Functional results (no anal incontinence)</th><th>Diverting stoma</th><th>Morbidity</th></tr></thead><tbody><tr><td>Oom et al. [32]</td><td>Puborectal sling interposition n = 11/11</td><td>n = 7/11</td><td>ND</td><td>ND</td><td>Wound infection n = 11/26 (all the etiologies)</td></tr><tr><td>Husain et al. [33]</td><td>Transperineal ELC n = 8/9 + Sphincteroplasty n = 2</td><td>n = 7/8</td><td>ND</td><td>n = 1/9</td><td>ND</td></tr><tr><td>Bai et al. [34]</td><td>Rectal ELC n = 2/3 Transvaginal ELC n = 1/3</td><td>v = 2/2 n = 1/1</td><td>ND</td><td>ND</td><td>ND</td></tr><tr><td>Zimmerman et al. [35]</td><td>ERAF n = 9/9</td><td>n = 4/9</td><td>n = 8/16</td><td>ND</td><td>Wound infection n = 2/21 dyspareunia n = 4/8 (all the etiologies)</td></tr><tr><td>Khanduja et al. [36]</td><td>ERAF + sphincteroplasty n = 20/20</td><td>n = 14/20</td><td>n = 14/20</td><td>None</td><td>ND</td></tr><tr><td>Veronikis et al. [37]</td><td>ERAF n = 22/22 + Overlapping sphincteroplasty n = 15/22 or perineal reconstruction with pubococcygeal muscle and deep transverse perineal muscle n = 19/22</td><td>n = 20/22</td><td>n = 18/22</td><td>None</td><td>Mechanical disimpaction n = 2 urinary retention (n = 3) fecaloma (n = 3) wound disrupton (n = 2)</td></tr><tr><td>Khanduja et al. [38]</td><td>ERAF n = 27/27</td><td></td><td>n = 16/27</td><td>None</td><td>n = 6/48 n = 2 hématoma n = 2 n fecaloma n = 2 urinary infection none</td></tr><tr><td>Russell and Gallagher [39]</td><td>ERAF n = 6/6</td><td>n = 5/6</td><td>n = 22/32 (all the etiologies)</td><td>None</td><td>ND</td></tr><tr><td>Browning et al. [40]</td><td>Flap splitting technic n = 18/18</td><td>v = 18/18</td><td>n = 16/18</td><td>None</td><td>ND</td></tr><tr><td>Tong et al. [27]</td><td>Ovesco clip n = 5/5</td><td>n = 1/5</td><td>n = 4/5</td><td>ND</td><td>ND</td></tr></tbody></table>

ERAF endorectal advancement flap, ELC excision and layered closure, IQR interquartile range

<figure><img src="image_7.png" /></figure>
<table><caption>**Table 3** Synthesis of the number of procedures performed according to the prospective and retrospective characteristic of the studies and their anatomical results</caption><thead><tr><th>Procedure</th><th>Number of studies</th><th>Number of procedures</th><th>Anatomical success</th></tr></thead><tbody><tr><td>Endorectal avancement flap</td><td>n=11 (Retro: n=6/Prosp: n=5)</td><td>n=180 (Retro: n=96/Prosp: n=84)</td><td>n=98/180 (Retro: n=39; 20–100%/<br>Prosp: n=59; 44–91%)</td></tr><tr><td>Musset procedure</td><td>n=14 (Retro: n=12/Prosp: n=3)</td><td>n=243 (Retro: n=206/Prosp: n=37)</td><td>n=184/243 (Retro: n=152; 65–100%/<br>Prosp: n=7; 64–100%)</td></tr><tr><td>Transperineal ELC</td><td></td><td></td><td></td></tr><tr><td>Transvaginal ELC</td><td>n=4 (Retro: n=3/Prosp: n=1)</td><td>n=62 (Retro: n=61/Prosp: n=1)</td><td>n=60/62 (Retro: n=59; 86–100%/<br>Prosp: n=1; 100%)</td></tr><tr><td>Rectal ELC</td><td>n=1 (Prosp)</td><td>n=2</td><td>n=2/2 (100%)</td></tr><tr><td>Simple suture</td><td>n=1 (Retro)</td><td>n=1</td><td>n=1/1 (100%)</td></tr><tr><td>Martius flap</td><td>n=5 (Retro: n=4/Prosp: n=1)</td><td>n=21 (Retro: n=20/Prosp: n=1)</td><td>n=13/21 (Retro: n=12; 50–100%/<br>Prosp: n=1; 100%)</td></tr><tr><td>Gracilis flap</td><td>n=3 (Retro exclusively)</td><td>n=14</td><td>n=10/14 (66–100%)</td></tr><tr><td>Glue</td><td>n=1 (Retro)</td><td>n=10</td><td>n=4/10 (40%)</td></tr><tr><td>Plug</td><td>n=1 (Retro)</td><td>n=7</td><td>n=3/7 (42%)</td></tr><tr><td>Puborectal sling interposition</td><td></td><td></td><td></td></tr><tr><td>Flap splitting technique</td><td></td><td></td><td></td></tr><tr><td>Vaginal flap</td><td>n=2 (Retro)</td><td>n=9</td><td>n=4/9 (37.5–100%)</td></tr><tr><td>Autologous fat graft</td><td>n=2 (Retro: n=0/Prosp: n=2)</td><td>n=13 (Prosp: n=13)</td><td>n=12/13 (92.4%)</td></tr><tr><td>Ovesco clip</td><td>n=2 (Retro: n=1; Prosp: n=1)</td><td>n=14 (Retro: n=9/Prosp: n=5)</td><td>n=4/14 (Retro: n=3/9; 33%/Prosp:<br>n=1/5; 20%)</td></tr><tr><td>Lift</td><td>n=1 (Retro)</td><td>n=1</td><td>n=1/1 (100%)</td></tr><tr><td>Plug</td><td>n=1 (Prosp)</td><td>n=2</td><td>n=1/2 (50%)</td></tr><tr><td>Abdominal access</td><td></td><td></td><td></td></tr><tr><td>Rectal and vaginal suture</td><td>n=1 (Prosp)</td><td>n=2</td><td>n=2/2 (100%)</td></tr><tr><td>Rectal resection</td><td>n=1 (Prosp)</td><td>n=1</td><td>n=1/1 (100%)</td></tr><tr><td>Pull-through technique</td><td>n=1 (Prosp)</td><td>n=5</td><td>n=4/5 (80%)</td></tr><tr><td>Spontaneous healing</td><td>n=3 (Retro)</td><td>n=8</td><td>ND</td></tr><tr><td>Total</td><td></td><td>n=595</td><td></td></tr></tbody></table>

Prosp prospective study, Retro retrospective study, ELC excision and layered closure, ND not defined

Stoma construction was reported in 24 studies, but only 10 reported the number of stoma constructions in the obstetric RVF group [6, 14–16, 22, 23, 25, 29, 31, 33]. In these 10 studies, 66 stomas were performed in 132 women. The significance of the stoma in improving the surgical success rate was only assessed in the study of Venara et al. [6], which reported that a stoma does not significantly improve the success rate (OR = 1.46; 95% CI: 0.31–6.91).

The functional results and the postoperative outcomes were not extensively reported in the literature (Tables 1 and 2). Furthermore, when morbidity was reported, the authors did not specify the etiology of the RVF.

## Results of the different procedures

The endorectal advancement flap (ERAF) is the most studied procedure in the literature. Six retrospective studies reported heterogeneous results ranging between 20 and

100%, while 5 prospective studies reported results from 44 to 91% (Table 3).

Excision and layered closure (ELC) was the second most frequently studied procedure. Three surgical accesses can be used: (1) the transperineal access (8 retrospective studies and 1 prospective study) reporting results from 80.5 and 100% and 87.5%, respectively; (2) the transvaginal access (3 retrospective studies and 1 prospective) reporting results from 83.3 to 100% (Table 3).

## Meta-analysis

Absence of postoperative fecal incontinence and construction of a diverting stoma were not mentioned frequently enough to allow performing a meta-analysis considering these endpoints. The only possible endpoint considered was the anatomical correction of the defect. A list of direct pairs for comparison presented by the considered studies is given in Fig. 2 (each line
<figure><img src="image_8.png" /><figcaption>**Fig. 2** Pairwise comparisons of the anatomical results presented in the considered studies (each line corresponding to a direct pairwise comparison, the width of the line illustrating the number of studies presenting such a pairwise comparison). ERAF endorectal advancement flap, Ov C Ovesco clip, Sph transp transperineal sphincteroplasty (excision and layered closure), sph transv transvaginal sphincteroplasty (excision and layered closure), P Sling puborectal sling</figcaption></figure>

corresponding to a direct pair for comparison, the width of the line illustrating the number of studies presenting such a pair for comparison). The absolute proportions of anatomical corrections of the defect depending on the considered treatments, associated with their 95% confidence intervals, are presented in Fig. 3. The Musset procedure, transvaginal ELC and transperineal ELC all presented significantly better results than the ERAF procedure (OR of 4.29; 95% CI: 1.18–16.14 for Musset procedure, 11.84; 95% CI: 2.18–91.80 for transvaginal ELC and 3.56; 95% CI: 1.26–10 for transperineal ELC). The odds ratios for each of the procedures studied are presented in Fig. 4.

## Quality of the studies included

The quality of the studies included was low because of the lack of randomized controlled studies. However, most of the studies had a good design and analysis (Table 4).

## Discussion

### Main findings

In this systematic review and meta-analysis including 18 retrospective studies and 14 observational prospective

studies, 595 women undergoing surgery for obstetric RVF were considered. The quality of the studies included was low because of the lack of prospective randomized studies. Nineteen procedure types were described and assessed. Most of the patients (n = 180) underwent ERAF followed by ELC (n = 213) and the Musset procedure (n = 65). A diverting stoma was performed in 66 of the 132 women in which it was reported. Only 13 studies reported the functional results of the procedure. In the meta-analysis, the ELC and Musset procedure gave the best results.

### Strength

To our knowledge, this is the first systematic review including only obstetric RVF women. The meta-analysis advocates proposing new principles and standards for RVF closure. The arm-based network meta-analysis based on the Zhang et al. Bayesian hierarchical models [12] is a relatively innovative methodology, particularly adapted to the context of the studies analyzed. Classical meta-analysis, focusing only on directly paired comparisons between two specific treatments, could not be considered because of the many possible surgeries [41]. Network meta-analysis allows considering a large number of possible treatments in a single analysis, even if the collection of studies identified through the systematic review does not specifically report each of the possible treatment pairs for comparison [42]. Classical contrast-based network meta-analysis methods do not allow considering single-arm studies (i.e., focusing the study on a given surgery) but only studies reporting results as relative effects (e.g., odds ratios). Only arm-based network meta-analysis methods could allow evaluation of both relative treatment effects (e.g., odds ratios) and absolute risks (e.g., overall percentage of success for each arm) while considering both single arm studies and studies comparing several treatments.

## Limitations

None of the studies were randomized controlled studies, and the quality assessment of the studies showed some to be inferior. However, to improve the quality of the data collected, the case reports were excluded considering that they only related to focal procedures. The patients included in the present meta-analysis came from cohort studies including all consecutive patients with RVF, limiting the selection bias, even if only one patient was included in the study. The perioperative management of the patients might also represent a bias in the analysis. Indeed, there is a lack of information about constructing a diverting stoma, and most of the studies do not report the results according to such a construction. To date, the role of diverting stoma construction is debated as some

<figure><img src="image_9.png" /></figure>
<figure><img src="image_10.png" /><figcaption>**Fig. 3** Absolute proportion of anatomical corrections of the defect depending on the considered treatment, associated with the 95% confidence interval. ERAF endorectal advancement flap, Ov C Ovesco</figcaption></figure>

clip, *Sph transp* transperineal sphincteroplasty (excision and layered closure), *sph transv* transvaginal sphincteroplasty (excision and layered closure), *P Sling* puborectal sling

studies conclude it does not improve the success rate [6, 43] while others counter this [44]. This difference may be due to the surgical procedure performed or to the etiology of the RVF included, obstetrical RVF having a higher rate of success than the other etiologies [5, 45]. As information about the stoma is not detailed in the studies, no assessment was feasible in a meta-analysis. Also, the predictors of the success of the surgery, such as a higher BMI and the number of repairs, were not considered in the present analysis [45, 46]. Finally, the description of the RVF was poorly reported in the studies and was therefore not collected. This may represent a bias. However, only obstetric RVFs were included in the present meta-analysis. This limits the risk of bias

because obstetric RVFs are usually short and associated with sphincter defects.

## Interpretation

While obstetric RVFs have a good prognosis with a reported healing rate between 40 and 100% [6, 8, 13, 15], women need a mean of 2.5 (± 1.7) procedures to heal the fistula [47]. The ASCRS recommends favoring the sphinctersparing procedure [48], explaining why most of procedures performed are ERAFs despite their variable results from 50 to 70% [48]. For RVF, the German guidelines state that no specific procedure can be recommended according to the literature [48]. At first sight, the ERAF may represent an easy
<figure><img src="image_11.png" /><figcaption>**Fig. 4** Comparison of the odds ratios for each of the procedures studied (reference: endorectal advancement flap). ERAF endorectal advancement flap, Ov C Ovesco clip, Sph transp transperineal sphincteroplasty (excision and layered closure), sph transv transvaginal sphincteroplasty (excision and layered closure), P Sling puborectal sling</figcaption></figure>

procedure with low morbidity, but a recent meta-analysis reports morbidity in 53.6% of the ERAFs performed in anorectal fistula [49]. The main complications reported were flap disruption and fecal incontinence [49]. In the context of RVF, a flap disruption can lead to an increase of the RVF opening, leading to consideration of the diverting stoma to increase the patient's quality of life or to reduce infection [50]. The present meta-analysis suggests that the Musset procedure or excision and layered closure could yield the best results. Literature on the Musset procedure is scarce

and does not provide information on the technique's morbidity [20] as comprehensively as for ELC. Due to this lack of information in the literature, it is not possible to make a recommendation, but the common aim of the Musset procedure and ELC is to repair the sphincter, indicating that sphincteroplasty should be performed during RVF repair.

Finding the best way to repair obstetric fistulas is an issue of utmost significance as it affects individuals very personally as well as communities more broadly, especially in LMIC [51], and it reduces quality of life [45]. Furthermore,

<figure><img src="image_12.png" /></figure>
<table><caption>**Table 4** JBI checklist for cohort and case studies of those included</caption><thead><tr><th colspan="13">JBI checklist = cohort study</th><th colspan="13">JBI checklist = case series</th></tr><tr><th></th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th><th>Yes</th></tr></thead><tbody><tr><td>Venara et al. [6]</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Beksiac et al. [13]</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Norderval, et al. [26]</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Reisenauer et al. [14]</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Hull et al. [9]</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td></tr><tr><td>Songne et al. [15]</td><td>Yes</td><td>Yes</td><td>No</td><td>No</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>NA</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td></tr><tr><td>Devesa et al. [16]</td><td>Yes</td><td>Yes</td><td>No</td><td>No</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>NA</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td></tr><tr><td>Chew et al. [17]</td><td>Yes</td><td>Yes</td><td>No</td><td>No</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>No</td><td>Yes</td><td>NA</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td></tr><tr><td>Rahman et al. [18]</td><td>Yes</td><td>Yes</td><td>No</td><td>No</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>No</td><td>Yes</td><td>NA</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td></tr><tr><td>Sonoda et al. [8]</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>No</td><td>Yes</td><td>NA</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td></tr><tr><td>Soriano et al. [19]</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>NA</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td></tr><tr><td>Ozuner et al. [20]</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>NA</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td></tr><tr><td>MacRae et al. No [21]</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>No</td><td>No</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td></tr><tr><td>Reisenauer et al. [22]</td><td>Yes</td><td>Yes</td><td>No</td><td>No</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td></tr><tr><td>Karp et al. [5]</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>No</td><td>Yes</td><td>NA</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td></tr><tr><td>Zmora et al. [23]</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Frontali et al. [25]</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td></tr><tr><td>Corman et al. [24]</td><td>Yes</td><td>Yes</td><td>No</td><td>No</td><td>Yes</td><td>Yes</td><td>Yes</td><td>Yes</td><td>No</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td><td>Unclear</td></tr></tbody></table>
as the number of the procedures is a risk factor for failure of further surgeries [45], the most efficient procedure has to be determined. Further randomized controlled study is required to confirm whether sphincteroplasty provides better anatomical and functional results than ERAF.

## Conclusion

Obstetric RVF is mainly repaired using ERAF, with poor results. ELC and the Musset procedure, which both allow sphincteroplasty, had better anatomical results. The literature review did not allow conclusions to be drawn about the value of diverting stoma in that context. Randomized controlled trials in the literature are required to assess and compare the anatomical and functional results of ERAF and sphincteroplasty as well as their related morbidity rates.

**Supplementary Information** The online version contains supplementary material available at https://doi.org/10.1007/s10151-025-03133-3.

**Author contribution** Venara Aurélien: conceptualization, methodology, formal analysis, investigation, resources, data curation, writing original draft, visualization, project administration. Elsa Houlet: conceptualization, methodology, formal analysis, investigation, resources, data curation, writing original draft, visualization, project administration. Emma Poupard: conceptualization, methodology, formal analysis, resources, data curation, writing original draft, visualization, supervision, writing review and editing. Matisse André: conceptualization, methodology, formal analysis, resources, data curation, writing original draft, visualization, supervision, writing review and editing. Pierre Emmanuel Bouet: conceptualization, methodology, formal analysis, resources, data curation, writing original draft, visualization, supervision, writing review and editing. Julien Gillet: conceptualization, methodology, formal analysis, resources, data curation, writing original draft, visualization, supervision, writing review and editing. Jean-François Hamel: conceptualization, methodology, formal analysis, investigation, resources, data curation, writing original draft, visualization, project administration. All the authors accept responsibility for the paper as published.

**Funding** Open access funding provided by Université d'Angers. None.

**Data availability** No datasets were generated or analyzed during the current study.

## Declarations

**Conflict of interest** The authors declare no competing interests.

**Ethical approval** Not applicable.

**Informed consent** For this type of study, formal consent is not required.

**Open Access** This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated

otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

## References

1. Vogel JP, Jung J, Lavin T, Simpson G, Kluwgant D, Abalos E et al (2024) Neglected medium-term and long-term consequences of labour and childbirth: a systematic analysis of the burden, recommended practices, and a way forward. Lancet Glob Health 12(2):e317–e330

2. Cowgill KD, Bishop J, Norgaard AK, Rubens CE, Gravett MG (2015) Obstetric fistula in low-resource countries: an under-valued and under-studied problem—systematic review of its incidence, prevalence, and association with stillbirth. BMC Pregnancy Childbirth 15:193

3. Saclarides TJ (2002) Rectovaginal fistula. Surg Clin North Am 82(6):1261–1272

4. Blondel B, Alexander S, Bjarnadóttir RI, Gissler M, Langhoff-Roos J, Novak-Antolič Ž et al (2016) Variations in rates of severe perineal tears and episiotomies in 20 European countries: a study based on routine national data in Euro-Peristat Project. Acta Obstet Gynecol Scand 95(7):746–754

5. Karp NE, Kobernik EK, Berger MB, Low CM, Fenner DE (2019) Do the surgical outcomes of rectovaginal fistula repairs differ for obstetric and nonobstetric fistulas? a retrospective cohort study. Female Pelvic Med Reconstr Surg 25(1):36–40

6. Venara A, Trilling B, Ngoma M, Brochard C, Duchalais E, Siproudhis L et al (2022) Ano-rectovaginal fistula after obstetrical anal sphincter injury: Diverting stoma does not improve the surgical results. Colorectal Dis 24(11):1371–1378

7. Vogel JD, Johnson EK, Morris AM, Paquette IM, Saclarides TJ, Feingold DL et al (2016) Clinical practice guideline for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula. Dis Colon Rectum 59(12):1117–1133

8. Sonoda T, Hull T, Piedmonte MR, Fazio VW (2002) Outcomes of primary repair of anorectal and rectovaginal fistulas using the endorectal advancement flap. Dis Colon Rectum 45(12):1622–1628

9. Hull TL, El-Gazzaz G, Gurland B, Church J, Zutshi M (2011) Surgeons should not hesitate to perform episioproctotomy for rectovaginal fistula secondary to cryptoglandular or obstetrical origin. Dis Colon Rectum 54(1):54–59

10. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71

11. Munn Z, Barker TH, Moola S, Tufanaru C, Stern C, McArthur A et al (2020) Methodological quality of case series studies: an introduction to the JBI critical appraisal tool. JBI Evid Synth 18(10):2127

12. Zhang J, Carlin BP, Neaton JD, Soon GG, Nie L, Kane R et al (2014) Network meta-analysis of randomized clinical trials: reporting the proper summaries. Clin Trials Lond Engl 11(2):246–262

13. Beksac K, Tanacan A, Ozgul N, Beksac MS (2018) Treatment of rectovaginal fistula using sphincteroplasty and fistulectomy. Obstet Gynecol Int. https://doi.org/10.1155/2018/5298214

14. Reisenauer C (2016) Presentation and management of rectovaginal fistulas after delivery. Int Urogynecology J 27(6):859–864

15. Songne K, Scotté M, Lubrano J, Huet E, Lefébure B, Surlemont Y et al (2007) Treatment of anovaginal or rectovaginal fistulas with modified Martius graft. Colorectal Dis 9(7):653–656
16. Devesa JM, Devesa M, Velasco GR, Vicente R, García-Moreno F, Rey A et al (2007) Benign rectovaginal fistulas: management and results of a personal series. Tech Coloproctology 11(2):128-134

17. Chew SSB, Rieger NA (2004) Transperineal repair of obstetric-related anovaginal fistula. Aust N Z J Obstet Gynaecol 44(1):68-71

18. Rahman MS, Al-Suleiman SA, El-Yahia AR, Rahman J (2003) Surgical treatment of rectovaginal fistula of obstetric origin: a review of 15 years' experience in a teaching hospital. J Obstet Gynaecol J Inst Obstet Gynaecol 23(6):607-610

19. Soriano D, Lemoine A, Laplace C, Deval B, Dessolle L, Darai E et al (2001) Results of recto-vaginal fistula repair: retrospective analysis of 48 cases. Eur J Obstet Gynecol Reprod Biol 96(1):75-79

20. Ozuner G, Hull TL, Cartmill J, Fazio VW (1996) Long-term analysis of the use of transanal rectal advancement flaps for complicated anorectal/vaginal fistulas. Dis Colon Rectum 39(1):10-14

21. MacRae HM, McLeod RS, Cohen Z, Stern H, Reznick R (1995) Treatment of rectovaginal fistulas that has failed previous repair attempts. Dis Colon Rectum 8(9):921-925

22. Reisenauer C, Amend B, Falch C, Abele H, Brucker SY, Andress J (2021) Evaluation and management of obstetric genital fistulas treated at a pelvic floor centre in Germany. BMC Womens Health 21(1):52

23. Zmora O, Tulchinsky H, Gur E, Goldman G, Klausner JM, Rabau M (2006) Gracilis muscle transposition for fistulas between the rectum and urethra or vagina. Dis Colon Rectum 49(9):1316-1321

24. Corman ML (1985) Anal incontinence following obstetrical injury. Dis Colon Rectum 28(2):86-89

25. Frontali A, Rottoli M, Chierici A, Poggioli G, Panis Y (2021) Rectovaginal fistula: Risk factors for failure after graciloplasty-A bicentric retrospective European study of 61 patients. Colorectal Dis 23(8):2113-2118

26. Norderval S, Lundby L, Hougaard H, Buntzen S, Weum S, de Weerd L (2018) Efficacy of autologous fat graft injection in the treatment of anovaginal fistulas. Tech Coloproctology 22(1):45-51

27. Tong JWV, Lingam P, Shelat VG (2020) Adhesive small bowel obstruction - an update. Acute Med Surg 7(1):e587

28. Mukwege D, Mukanire N, Himpens J, Cadière GB (2016) Minimally invasive treatment of traumatic high rectovaginal fistulas. Surg Endosc 30(1):379-387

29. de Weerd L, Weum S, Norderval S (2015) Novel treatment for recalcitrant rectovaginal fistulas: fat injection. Int Urogynecology J 26(1):139-144

30. Schwandner O, Fuerst A, Kunstreich K, Scherer R (2009) Innovative technique for the closure of rectovaginal fistula using Surgisis mesh. Tech Coloproctology 13(2):135-140

31. Cui L, Chen D, Chen W, Jiang H (2009) Interposition of vital bulbocavernosus graft in the treatment of both simple and recurrent rectovaginal fistulas. Int J Colorectal Dis 24(11):1255-1259

32. Oom DMJ, Gosselink MP, Van Dijl VRM, Zimmerman DDE, Schouten WR (2006) Puborectal sling interposition for the treatment of rectovaginal fistulas. Tech Coloproctology. https://doi.org/10.1007/s10151-006-0265-2

33. Husain A, Johnson K, Glowacki CA, Osias J, Wheeless CR, Asrat K et al (2002) (2005) Surgical management of complex obstetric fistula in Eritrea. J Womens Health 14(9):839-844

34. Bai SW, Kim SH, Kwon HS, Rha KH, Chung KA, Kim SK et al (2002) Surgical outcome of female genital fistula in Korea. Yonsei Med J 43(3):315-319

35. Zimmerman DDE, Gosselink MP, Briel JW, Schouten WR (2002) The outcome of transanal advancement flap repair of rectovaginal fistulas is not improved by an additional labial fat flap transposition. Tech Coloproctology 6(1):37-42

36. Khanduja KS, Padmanabhan A, Kerner BA, Wise WE, Aguilar PS (1999) Reconstruction of rectovaginal fistula with sphincter disruption by combining rectal mucosal advancement flap and anal sphincteroplasty. Dis Colon Rectum 42(11):1432-1437

37. Veronikis DK, Nichols DH, Spino C (1998) The noble-mengert-fish operation-revisited: a composite approach for persistent rectovaginal fistulas and complex perineal defects. Am J Obstet Gynecol. https://doi.org/10.1016/S0002-9378(98)70003-1

38. Khanduja KS, Yamashita HJ, Wise WE, Aguilar PS, Hartmann RF (1994) Delayed repair of obstetric injuries of the anorectum and vagina. A stratified surgical approach. Dis Colon Rectum. https://doi.org/10.1007/BF02053595

39. Russell TR, Gallagher DM (1977) Low rectovaginal fistulas. Approach and treatment Am J Surg 134(1):13-18

40. Browning A, Menber B (2008) Women with obstetric fistula in Ethiopia: a 6-month follow up after surgical treatment. BJOG Int J Obstet Gynaecol 115(12):1564-1569

41. The Handbook of Research Synthesis and Meta-Analysis, Second Edition | RSF [Internet]. [cité 17 mars 2024]. Disponible sur: https://www.russellsage.org/publications/handbook-research-synthesis-and-meta-analysis-second-edition

42. Lumley T (2002) Network meta-analysis for indirect treatment comparisons. Stat Med 21(16):2313-2324

43. Fu J, Liang Z, Zhu Y, Cui L, Chen W (2019) Surgical repair of rectovaginal fistulas: predictors of fistula closure. Int Urogynecology J 30(10):1659-1665

44. Corte H, Maggiori L, Treton X, Lefevre JH, Ferron M, Panis Y (2015) Rectovaginal fistula: what is the optimal strategy?: an analysis of 79 patients undergoing 286 procedures. Ann Surg. https://doi.org/10.1097/SLA.0000000000001461

45. Söderqvist EV, Cashin PH, Graf W (2022) Surgical treatment of rectovaginal fistula-predictors of outcome and effects on quality of life. Int J Colorectal Dis 37(7):1699-1707

46. El-Gazzaz G, Hull TL, Mignanelli E, Hammel J, Gurland B, Zutshi M (2010) Obstetric and cryptoglandular rectovaginal fistulas: long-term surgical outcome; quality of life; and sexual function. J Gastrointest Surg Off J Soc Surg Aliment Tract 14(11):1758-1763

47. Venara A, Trilling B, Ngoma M, Brochard C, Duchalais E, Siproudhis L, Faucheron JL, de Parades V, Alves A, Cotte E, Ouaissi M, Bridoux V, Corbière L, Heraud J Jr, Ortega-Deballon P, Aboulhassan F, Hamel JF (2022) Ano-rectovaginal fistula after obstetrical anal sphincter injury: Diverting stoma does not improve the surgical results. Colorectal Dis 24(11):1371-1378

48. Ommer A, Herold A, Berg E, Fürst A, Schiedeck T, Sailer M (2012) German S3-guideline: rectovaginal fistula. GMS Ger Med Sci. 10:Doc15

49. Emile SH, Garoufalia Z, Aeschbacher P, Horesh N, Gefen R, Wexner SD (2023) Endorectal advancement flap compared to ligation of inter-sphincteric fistula tract in the treatment of complex anal fistulas: A meta-analysis of randomized clinical trials. Surgery 174(2):172-179

50. Garg P, Yagnik VD, Dawka S (2021) Fecal diversion in complex anal fistulas: Is there a way to avoid it? World J Clin Cases 9(25):7306-7310

51. Ahmed SAE, Thorsen VC (2019) "I feel myself incomplete, and I am inferior to people": experiences of Sudanese women living with obstetric fistula in Khartoum. Sudan Reprod Health 16(1):183

**Publisher's Note** Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.