The Disappointing Quality of Published Studies on Operative Techniques for Rectovaginal Fistulas: a Blueprint for a Prospective Multi-institutional Study

BACKGROUND: Treatment of rectovaginal fistulas is difficult, and many surgical interventions have been developed. The best surgical intervention for the closure of these fistulas is still unclear. OBJECTIVE: A systematic review was performed reporting the outcomes of different surgical techniques for rectovaginal fistulas. DATA SOURCES: Medline (PubMed, Ovid), Embase (Ovid), and The Cochrane Library databases were searched for eligible articles as well as the references of these articles. STUDY SELECTION : Two independent reviewers analyzed the search results for eligible articles based on title, abstract, and described results. Intervention(s): Any surgical intervention for the closure of rectovaginal fistulas was included. MAIN OUTCOME MEASURES: The main outcome was closure rate. Secondary outcomes were quality of life, morbidity, and the effect on sexual functioning. RESULTS: Many articles with different operative techniques were identified and classified in the following categories: advancement flaps (endorectal and endovaginal), transperineal closure, Martius procedure, gracilis muscle transposition, rectal resections, transabdominal closure, mesh repair, plugs, endoscopic repairs, closure with biomaterials, and miscellaneous techniques. Results vary widely with closure rates between 0% and > 80%. None of the studies were randomized. Because of the poor quality of the identified studies, the comparison of results and performance of a meta-analysis were not possible. Data regarding the secondary outcomes were mostly unavailable. LIMITATIONS : The major limitation of this review was the limited availability of high-quality prospective studies, making it impossible to perform a meta-analysis. CONCLUSIONS : No conclusion about the best surgical intervention for rectovaginal fistulas could be formulated. More large studies of high quality are needed to find the best treatment for rectovaginal fistulas. A design for these high-quality studies was formulated.