Rectovaginal Fistula: What Is the Optimal Strategy? An Analysis of 79 Patients Undergoing 286 Procedures

Objectives:The aim of this study was to assess results of surgery for rectovaginal fistula (RVF) and prognostic factors for success.Background data:Management of RVF remains challenging and numerous surgical options are available. Few large reports of RVF are available and success prognostic factors remain unknown.Methods:All patients operated for RVF from 1996 to 2014 were included.Results:Seventy-nine patients presented RVF due to Crohn disease in 34 (43%), postoperative in 25 (32%), obstetrical in 7 (9%), radiation proctitis in 4 (5%), and miscellaneous in 9 (11%). A total of 286 procedures (132 with associated stoma, 46%) were performed including 217 conservative (76%) [seton drainage (n=59; 21%), vaginal (n=49, 17%) or rectal advancement flap (n=46; 16%), diverting stoma only (n=27; 9%), plug (n=15; 5%), glue (n=13; 5%), or others (n=8, 3%)]; and 69 major procedures (24%) [gracilis muscle interposition (n=32; 11%), coloanal or colorectal anastomosis (n=19; 7%) including 11 delayed anastomosis with colonic pull-through, biomesh interposition (n=9, 3%), and abdominoperineal resection (n=9; 3%)]. After a mean follow-up of 33 months, overall success rate was 57 of 79 (72%). Per-procedure-based multivariate analysis identified major procedure [odds ratio (OR): 6.4 (2.9-14.2); P<0.001], diverting stoma [OR: 3.5 (1.4-8.7); P=0.009], less than 9 months between diagnosis and first surgery [OR: 2.3 (1.1-5.3); P=0.046], and first surgery in our institution [OR: 3.2 (1.5-6.9); P=0.003], as independent factors for success.Conclusions:Our study suggested that aggressive surgical treatment of RVF, including early use of temporary stoma and major procedure in case of failure of previous local treatment, leads to high success rates.