Transperineal Repair of Primary Obstetric Rectovaginal Fistulas
Condition: Recto Vaginal Fistula
MeSH terms: Rectovaginal Fistula; Vaginal Fistula; Fistula
Study type: Interventional

Summary: 
      Introduction: A rectovaginal fistula (RVF) is an epithelium-lined abnormal tract between the
      rectum and the vagina and is often a challenging problem for both the patients and to the
      surgeons. In literature, there is still debate regarding the best treatment options for
      rectovaginal fistulas.

      Aim: To assess the results of the treatment of rectovaginal ﬁstulas with incontinence and
      impaired anal tonus using fistulectomy, sphincteroplasty with or without bulbocavernosus
      muscle (Martius) flap.

      Materials and Methods: A total of 22 consecutive patients with simple RVFs were included and
      assigned to transperineal repair. The patients were divided into two groups , group1: with
      Martius flap; group2: without Martius flap .Postoperatively, patients were followed up for
      one year at the outpatient clinic or through telephone interviews with speciﬁc questionnaires
      to collect information on the status of fecal control, ﬂatus, or fecal leakage from the
      vagina.
    

Detailed description: 
      Introduction:

      Rectovaginal ﬁstulas represent an often devastating condition in patients and a challenge for
      surgeons because of their irritating and embarrassing symptoms and high failure rate after
      repair.Patients with rectovaginal ﬁstulas typically present with complaints of passage of
      ﬂatus or feces from the vagina with painful skin excoriation.

      (1) The most common etiological cause of rectovaginal ﬁstulas is obstetrical trauma. When
      obstructed labor is unrelieved, the presenting fetal part is impacted against the soft
      tissues of the pelvis leading to ischemic vascular injury and subsequent tissue necrosis and
      ﬁstula formation. Other predisposing factors include forceps delivery, midline episiotomy,
      and third or fourth-degree perineal lacerations.( 2).

      Evaluation of a patient with rectovaginal ﬁstula includes a detailed history, examination of
      the rectum, vagina, and perineal body. The perineal body is often thin or nearly nonexistent
      in patients with sphincter injuries secondary to obstetrical trauma. Endoanal ultrasonography
      and pelvic Magnetic Resonance Imaging (MRI) to conﬁrm sphincter injury and may provide
      valuable information before a planned repair. MR is the modality of choice for disease
      staging (sensitivity 91%) (3).

      ( Sagittal T2 MR imaging shows communication between the rectum tumor and the vagina) The
      experience of the surgeon and the previous attempts at repair are also important factors of
      the success rate of the operations [4)

      There are various operative procedures, such as the advancement ﬂap, sphincteroplasty and
      ﬁstulectomy, coloanal anastomosis,and gracilis muscle repair to manage rectovaginal ﬁstulas
      [5].

      The choice of the operative technique greatly depends on the status of the ﬁstula and the
      etiological rationale behind this medical complication [6.].

      In this study, we have compared the outcomes of the ﬁstulectomy and sphincteroplasty
      procedures with or without concomitant bulbocavernosus flap. All patients were incontinent
      and felt to have impaired anal tonus.

      Patients and method:

      Study design:

      This prospective study involved 22 patients diagnosed with simple rectovaginal fistula from
      January 2018 to January 2019 at the General surgical department, faculty of medicine Zagazig
      University, Egypt. This study was approved by the institutional ethics board of our hospital.
      All patients who participated in the study provided informed consent.

      rectovaginal examination, endoanal ultrasonography, and pelvic MRI ﬁndings were collected to
      assess the extension of the fistula. Colonoscopy was performed in selected patients with
      severe bowel symptoms such as bloody diarrhea to exclude inflammatory bowel disease.
      Decisions regarding operations were made cautiously and involved the whole medical team. All
      cases underwent fistulectomy, sphincteroplasty and with or without bulbocavernosus flap
      technique.All patients were evaluated for incontinence using Wexner Incontinence Score (WIS)
      [7) Method of randomization: simple randomization with a balance.

      Patient selection:

      Inclusion criteria:

        1. Rectovaginal fistula caused by obstetric problems

        2. Female >20 years

      Exclusion criteria:

        1. other causes of rectovaginal fistula as Crohn's disease or malignant fistula

        2. complex and recurrent fistula

      Three patients did not undergo surgery. One because of patient's choice, one because of
      minimal symptoms and one because fistula healed after medical therapy.

      Methods:

      Patients were given a mechanical bowel preparation the day before surgery and an enema on the
      morning of the operation. The patient was placed in the lithotomy position under spinal
      anesthesia. Antibiotics in the form of third generation cephalosporin and 500 mg of
      Metronidazole were given.

      Sub mucosal lidocain 5% in adrenalized saline at a ratio of 1: 100 000 was injected around
      the fistula. Surgical excision of the fistula using scalpel was performed. Biopsies of rectal
      mucosa and the fistula margin were also obtained for pathological evaluation to exclude an
      underlying Crohn's disease or malignancy. A transverse perineal incision was done. Dissection
      of the internal sphincter fibers away from the external sphincter fibers was performed,
      allowing a tension free rectal closure at the fistulous site (Dissection of internal
      sphincter ﬁ bers from external sphincter ﬁ ber s.). Closure of the fistulous opening at the
      rectal side was done using Vicryl 3/0 sutures. This was followed by suturing of the
      rectovaginal septum to the internal sphincteric fibers using Vicryl 3/0 sutures (Suturing of
      internal sphincter ﬁ bers to the rectovaginal septu m.). The bulbocavernosus muscle flap was
      harvested from the left side in all patients at its anterior part, preserving the
      posteroexternal vascular pedicle (Posterior muscle repair), through the same incision, and
      sutured across the rectum to its counterpart on the other side (Vaginal advancement ﬂ a p.&
      Fig. 1 a The fistulae are indicated by the two forceps passing through them; b The finger
      demonstrates the large recto-vaginal orifice) using 2/0 Vicryl sutures. The vaginal flap was
      advanced at the fistula site and sutured to the perineal skin using Vicryl 3/0 sutures
      (Preparation of the bulbocavernosus ﬂ a p.& Fig. 3 a, b After a right labial incision, the
      bulbocavernous muscle and the surrounding fibroadipose tissue were carefully mobilized,
      avoiding possible damage of the postero-external vascular pedicle& Fig. 4 A subcutaneous
      tunnel connecting the two incisions was created after transecting superior to the
      bulbocavernous muscle& Fig. 5 The final set-up with the interrupted absorbable sutures over
      the vaginal closure after sectioning of the longitudinal vaginal septum. The bulbocavernous
      muscle is clearly visible after the lay open of the perineovaginal tract).

      No suction drain was used. No covering stoma was done. Postoperatively, Soft, stool was
      provided in the postoperative period at least for two weeks with the help of clear liquid
      diet, plenty ﬂuid intake, and the use of stool softeners. Oral broad-spectrum antibiotic
      therapy was given for 3-5 days postoperatively. Sexual activity or any physical activities
      more strenuous than a slow walk were avoided by the patients for three weeks after the
      surgery. Follow up period up to one year.
    

Intervention name(s): rectovaginal fistula repair with Martius flap
Intervention type(s): Procedure
Intervention description(s): rectovaginal fistula repair with Martius flap
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Participant)
Primary purpose: Treatment