Complex Rectovaginal Fistula Repair

Rectovaginal fistula (RVF) is an abnormal epithelialized communication between the rectum and vagina, classified by location (low, mid, high), size, etiology, and number of failed prior repairs. Complex RVF is defined by recurrent fistula, large size (>2.5 cm), radiation history, Crohn disease, prior pelvic surgery, or sphincter involvement requiring advanced reconstructive techniques.

Common etiologies are obstetric trauma (most common globally), pelvic surgery (hysterectomy, low anterior resection, stapled hemorrhoidectomy), Crohn disease, radiation for cervical or rectal cancer, malignancy, infection, and trauma. Symptoms include passage of stool or gas through the vagina, recurrent vaginitis, fecal incontinence (with sphincter injury), and severe psychosocial distress.

Preoperative evaluation includes pelvic MRI for fistula tract mapping, endoanal ultrasound for sphincter assessment, colonoscopy for Crohn screening, and EUA for vaginal/rectal examination under anesthesia. Surgical options include transanal advancement flap, transvaginal repair with episiotomy approach, abdominal repair (low anterior resection or pull-through) for high RVF, and tissue interposition (Martius bulbocavernosus flap, gracilis muscle flap, omental flap) to bring vascularized non-irradiated tissue between repairs. Diverting loop ileostomy is often required for high-risk repairs and Crohn-associated RVF. Recurrence rates remain 20-50% with complex RVF requiring multiple staged operations and dedicated colorectal-urogynecology team.