Rectal sleeve advancement for the treatment of persistent rectovaginal fistulas

Background: Different surgical procedures are available for rectovaginal fistula repair. Most of these procedures fail in a substantial number of women, especially in those with a persistent fistula after prior attempts at repair. In addition, these procedures have a potential risk of dyspareunia and impairment of continence. The question is whether rectal sleeve advancement could be a valuable option for women with such a persistent rectovaginal fistula. The present study was aimed to examine the feasibility of this new procedure. Patients and methods: Eight consecutive women (median age 41 years; range 28-53) with a persistent, low rectovaginal fistula underwent rectal sleeve advancement, six patients by a posterior "Kraske" approach and two patients by an abdominal approach. The aetiologies were obstetric trauma (n = 4), prior anal surgery (n = 2) and cryptoglandular fistulous disease (n = 2). Results: Five patients had an uneventful postoperative course. Three patients encountered recurrent symptoms shortly after the procedure. In these three patients an additional transanal approach was performed to close the anal opening of the fistulous tract. This additional approach was successful in one patient. The median duration of follow-up was 12 months (range 3-17). The overall healing rate was 75%. None of the patients encountered de novo dyspareunia. One patient encountered involuntary loss of stool during the night postoperatively. Conclusion: Based on these early results, rectal sleeve advancement, either by a posterior "Kraske" approach, or by an abdominal approach, seems to be a valuable alternative for the treatment of persistent rectovaginal fistulas.

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