Rectovaginal and rectourethral fistulas

DR RAM RAKSHA PALFNB(MAS)

MMHRC, MADURAI

Rectovaginal and Rectourethral Fistulas

Rectovaginal Fistulas

epithelial-lined communications between the rectum and vagina.

relatively uncommon, 5% of all anorectal fistulas

significant physical symptomsadversely affecting intimate relationships and

sexual function. The lack of a uniformly successful surgical

repair is a source of great frustration to both patients and surgeons

Etiology

Obstretic causesFistulizing chrohn’s diseaseMalignancy of the cervix, rectum, uterus, or vaginaPost surgeryPost radiotherapyTraumaAnorectal suppurative diseasesOther infections- TB, LGV, HIV, CMV Less common causes- congenital fistulas, fecal

impaction, long-standing pessary usage, sexual assault, and ergotamine suppository usage

Obstetrical injuries 30-88% Inflammatory bowel disease 6-23% Prior surgery 7% Infections 5-10% Others ( radiation, cancers, rare causes and

unknown) <5%

Classification

Although rectovaginal fistulas occur anywhere along the rectovaginal septum, they most commonly arise from the region of the dentate line and communicate with the posterior vaginal fornix.

Fistulas distal to the dentate line are more appropriately termed anovaginal fistulas but common usage terms all such fistulas as rectovaginal fistulas.

Classified as low, mid, or high. In low fistulas, the opening is near the

posterior vaginal fourchette; In high fistulas, the opening is behind or near

the cervixmid rectovaginal fistulas are midway between

the two. From a practical standpoint, fistulas may be

classified as those palpable on digital examination and within view of an anoscope or those that are not.

Simple fistulas arise from obstetric trauma or infection and are relatively small,

complex fistulas are caused by inflammatory bowel disease, irradiation, cancer, or failed prior repairs.

Complex fistulas may also result from complications of surgery- after low anterior anastomosis (as a consequence of anastomotic leak) or after hysterectomy (as a result of unrecognized injury to the rectum).

Presentation

passage of stool or air per vaginafoul-smelling vaginal discharge with recurrent

vaginitis or urinary tract infectionsIn women with rectovaginal fistulas from an

obstetric injury, the incidence of incontinence is close to 50%.

The true incidence of incontinence is difficult to determine because passage of air and stool through the vagina may be interpreted as fecal incontinence.

Associated symptoms,such as diarrhea, abdominal pain, or mucous discharge, are suggestive of inflammatory bowel diseaseDelayed evaluation because of social embarrassment, the desire to have more

children, or the belief that such symptoms “are to be expected” after childbirth

EXAMINATION AND DIAGNOSIS

Identify the fistula

Assess the surrounding tissues

entire rectovaginal septum should be assessed sphincter defect significant scarring, stenosis, and tissue defects may require

tissue transfer techniques to maximize the chance of success with repair

Low rectovaginal fistulas are easily visualized and palpated on examination.

A dimple is palpated in the anterior midline on digital rectal

examination and confirmed on anoscopic or speculum examination.

Probe

Examination with one finger in the rectum and one in the vagina assists in assessing the surrounding tissues and the bulk of the rectovaginal septum.

An attenuated or absent perineal body and anterior sphincter defect are often noted in patients with previous obstetric injury.

Limited barium enema examination with a lateral view

A tampon placed in the vagina and a dilute methylene blue enema instilled in the rectum. The presence of methylene blue on the tampon confirms the fistula is present and open.

Water is placed in the vagina, and air is insufflated into the rectum with a sigmoidoscope. The presence of air bubbles in the vagina indicates a fistula.

IMAGING

transrectal ultrasound with use of hydrogen peroxide, vaginography, and magnetic resonance imaging (MRI), may demonstrate a rectovaginal fistula

in vivo identification of the fistula in the affected patient is must

Imaging studies are more useful in patients with mid- or

high fistulas, especially patients with colovaginal or enterovaginal fistulas

Low rectovaginal fistulas are generally straightforward to demonstrate on physical examination.

Assessment of the anatomy and function of the sphincter muscles is essential

In one study of primiparous women who had undergone a vaginal delivery alone, 28% had a sphincter defect on ultrasound examination 6 weeks after delivery.

One study suggested a 100% incidence of sphincter injuries on endoanal ultrasound in patients who sustained a rectovaginal fistula after vaginal delivery.

in one series of 52 women who had a rectovaginal fistula from obstetric injury, 50% had preoperative incontinence.

ultrasound and anal manometry with pudendal nerve terminal motor latency studies, are helpful in evaluating patients with associated incontinence.

Treatment

depends on a number of factors, including the site of the fistula, the cause of the fistula, surgical expertise, and the presence of an associated sphincter defect and incontinence.

With thorough preoperative evaluation, consideration of

optimal treatment options, and meticulous surgical technique, a successful repair is achieved in the majority of patients

Quality of life and sexual function following repair of

rectovaginal fistula are infrequently reported

despite successful repair, postoperative quality of life and sexual activity remain significantly altered.

Treatment options

Although the mainstay of treatment for the majority of rectovaginal fistulas is surgery, there are a few exceptions.

bowel management A small number of fistulas may close spontaneously

after obstetric trauma in the immediate postpartum period

Hyperbaric oxygen has been reported to be associated with successful healing in small series of patients with rectovaginal fistulas from obstetric trauma.

Medical therapy

Immunomodulation- rectovaginal fistulas in patients with Crohn disease

Although the initial trial utilizing infliximab in 1999 showed short-term healing in 56% to 68% of abdominal and perianal

fistulas, no rectovaginal fistulas were included.

Subsequently, the ACCENT II trial looked at 25 women with Crohn rectovaginal fistulas. With infliximab, 60.7% healed initially, but long-term closure (at 14 weeks) was significantly lower, with a closure rate of 44.8%

Compared with other fistulas, the rate of healing with

infliximab with rectovaginal fistulas is substantially less

Poritz et al have suggested that use of infliximab does not avoid the need for surgery in more than 70% of patients; however, such patients may be rendered relatively asymptomatic and have reasonable quality of life before requiring surgical intervention.

Infliximab and other immunomodulators are increasingly used as an adjunct to surgery.

Infliximab in combination with surgery for Crohn

rectovaginal fistulas appear to improve outcome

SURGICAL OPTIONS FOR R-V FISTULAS

Local repairs are performed through a rectal, vaginal, or perineal approach and may be augmented with tissue transfer, such as gracilis and bulbocavernosus muscle, if the surrounding tissues are deficient or unsatisfactory.

High rectovaginal fistulas or those associated with previous surgery or

radiation therapy generally require an abdominal approach.

Local repairs and abdominal repairs can be performed with fecal diversion,

fecal diversion may also be used, in selected patients, as the sole treatment for rectovaginal fistula.

The choice of repair depends on a variety of factors, including the presence of associated incontinence, the size and location of the fistula, the degree of complexity of the fistula, and the status of the surrounding tissues.

All procedures for rectovaginal fistula repair have a significant failure rate

Although fistula closure is ultimately achieved, a number of patients require more than one operation.

Cigarette smoking is increasingly recognized as a predictor for adverse outcome and recurrent fistula.

Preoperative discussionanticipated resultsabnormally high patient expectations need to

be adjusted Quality of life and assessment of dyspareunia

and sexual dysfunction after rectovaginal fistula surgery have not been rigorously evaluated in the majority of studies

TIMING OF SURGERY

Controversial

No level I evidence comparing immediate repair with secondary repair

If recognized at the time of delivery, initial repair is performed at the time of the delivery by the obstetrician.

surrounding tissues- soft and pliable. The convention, particularly for fistulas of obstetric

origin, has been to wait approximately 3 months, to maximize the condition of the surrounding tissues and also since a small percentage of fistulas close spontaneously in the immediate postpartum period

Data from series of patients with rectovaginal fistulas who have undergone MRI have challenged this dogma, because obstetric fistulas have short tracts and little associated inflammatory change on MRI compared with perianal fistulas.

For patients whose previous repair has failed, a waiting period of 3 to 6 months has been advocated that permits some healing of the surrounding tissues and often decreases the size of the recurrent fistula

Waiting for 3 to 6 months may also give both surgeon and patient a much needed reprieve from further surgical intervention.

LOCAL REPAIR- Sliding Flap Repair

first reported by Noble in 1902 used for simple low fistulas who have not had

previous repairs Patients with rectovaginal fistula from

obstetric injuries (without an associated sphincter defect) and patients with Crohn rectovaginal fistulas without associated proctitis are good candidates for sliding flap repair.


Mechanical bowel preparation- controversial

prone jackknife position, with the buttocks taped apart and the anal canal and fistula tract exposed

The intersphincteric groove is infiltrated with a combination of saline solution and epinephrine.

A trapezoidal flap composed of mucosa, submucosa, and a portion of the internal sphincter is raised.

The base of the flap should be at least twice the width of the apex, and mobilization should be continued for at least 4 cm.

Before the flap is advanced, the internal sphincter is mobilized

and approximated over the fistula. The flap is then advanced down the anal canal and secured

with absorbable sutures.

If the patient is incontinent or has a sphincter defect, a concomitant sphincteroplasty is performed


Modifications- Ozuner et al recommended a curvilinear flap

incorporating mucosa, submucosa, and internal sphincter to avoid ischemia at the angled corners.

Advancement of the entire rectal wall has been advocated for treatment of rectovaginal fistulas associated with Crohn disease with extensive scarring of the anal canal and multiple fistula tracts.

LOCAL REPAIR- Sliding Flap Repair : Outcomes

The success rate varies considerably, from 29% to 100%

related to the heterogeneity of the patient groups in addition to variations in surgical technique.

Common causes of flap failure include ischemia of the flap and hematoma, infection under the flap.

the number of previous repairs, the presence of a concomitant sphincter defect, and the cause of the rectovaginal fistula.

Transvaginal Techniques of Local Repair

Although a transvaginal approach addresses the fistula from the lower pressure vaginal side, not the higher pressure rectal side

allows for good exposure, and the ability to perform a concomitant sphincteroplasty if needed

lithotomy position

An incision is made in the posterior vaginal wall by the introitus, and the flap is raised in a similar manner on the vaginal side and advanced.


As with a rectal flap, the flap should be wide enough to ensure good blood supply and mobility.

This approach may have an advantage in

selected patients, especially patients with Crohn disease, because nondiseased, pliable vaginal tissue is used to form the flap, and there is little manipulation or dissection in the diseased rectum.


Using this technique, Bauer et al reported cure of the rectovaginal fistulas in 12 of 13 women with Crohn disease, with mean followup time of 50 months.

A transvaginal flap may also be useful in patients with pouch-vaginal fistula, obviating the need for a potentially difficult transanal approach.

ANOCUTANEOUS FLAP TECHNIQUE

limited experience with use of anocutaneous flaps, raising anoderm and perianal skin and advancing this into the anal canal.

used for very distal fistulas

limited application because of the lack of adequate perineal skin between the rectum and vagina in most patients with rectovaginal fistulas.

Advancement Sleeve Flap

rectovaginal fistula will develop in up to 10% of women with Crohn disease.

difficult to treat.

For patients with associated severe anorectal and colonic disease, proctocolectomy with ileostomy is the best option.

In selected patients with Crohn disease and a normal rectum, a local procedure can be considered.

Commencing at the level of the dentate line, a circumferential dissection of mucosa and submucosa is performed, thus excising the ulcerated areas of the anal canal.

The dissection is continued cephalad and into the supralevator space, completing rectal mobilization.

The fistula can then be cored out and closed, and the distal cuff (dotted line) of the rectum is trimmed and secured to the anoderm.

An additional modification was reported by Schouten et al, who employed either a posterior “Kraske” approach or an abdominal approach in 8 women with persistent low rectovaginal fistula, with overall healing in 75%.

No patient had dyspareunia, which may be an advantage to this technique compared to tissue interposition techniques, which may be associated with higher risks of dyspareunia.

The advancement sleeve flap is a good option for patients with persistent fistulas despite other local procedures, and patients in whom the only other option is fecal diversion or proctectomy

Transperineal Repair

Includes:

transperineal repair with layered closure with fistula repair

perineoproctotomy (which essentially converts the fistula to a full-thickness laceration) followed by layered repair

Transperineal Repair with Layered Closure

one of the most common operations performed for rectovaginal fistula.

It may be performed as the sole procedure or combined with sliding flap repair.

involves an overlapping sphincteroplasty

indicated for simple rectovaginal fistulas with an associated sphincter defect.

Overlapping sphincteroplasty. A, a curvilinear incision is made approximately 180 degrees around the anus. B, Dissection is carried out medial to the ischiorectal fat, and the external sphincter is identified. C, Dissection is carried up to the level of the levatores, which are plicated.

D, If sufficient muscle is present, an overlapping sphincter repair is performed. If not, simple apposition of the sphincter muscle is performed. E, The completed repair. F, The perineal body is reconstructed, and the wound is secured in a Y configuration. A drain may be placed


a curvilinear incision is made in the perineum around the anus, and the edges of the external and internal sphincter muscles are identified and mobilized.

Scar tissue is usually left in place on the muscle

and not debrided.

Care is taken to preserve the pudendal nerves that enter posterolaterally


In the course of the dissection, the fistula is identified, and the dissection is carried cephalad, separating the rectum and vagina for several centimeters until soft pliable tissue is reached.

The levator muscles are identified and plicated, which adds to

the muscle bulk and appears to provide better results from a continence standpoint.

The perineal skin may be either closed loosely or left open. The vaginal mucosa is left open for drainage.

Sphincteroplasty for rectovaginal fistula is associated with success rates of 65% to 100%.

Perineoproctotomy with Layered Closure

the fistula is converted to a fourth-degree perineal laceration.

The tract is then excised, and the vagina, sphincter muscles, and rectal mucosa are identified, mobilized, and repaired in layers.

Excellent results have been reported in several series. Mazier et al reported a success rate of 100% in 38 patients who underwent perineoproctectomy.

Perineoproctotomy with Layered Closure

Fistulotomy

Should be avoided because of the risk of significant incontinence from transection of the internal and external sphincter.

In a small series of eight patients who underwent this procedure, all patients had postoperative incontinence and required a second procedure

Autologous Fibrin Glue

Shown some success in selected cases

May be suitable for rvf with a long tract.

a minimally invasive technique without significant complications

high failure rate because the tract is characteristically too short to hold the glue for any length of time.

Autologous Fibrin Glue

Fibrin glue has also been used as an adjunct with other procedures such as endorectal advancement flap.

In one series, fibrin glue was combined with an endorectal advancement flap in 12 patients; the failure rate was 50%, which was not significantly different than patients who had endorectal advancement flap alone.

Despite initial enthusiasm, the technique is

generally not used for rectovaginal fistulas.

Collagen Fistula Plug/Rectovaginal Fistula Button

high failure rate because of early dislodgement of the plug from the short tract

The button fistula plug was used in 12 patients with a rectovaginal fistula (n = 5) or pouch-vaginal fistula (n = 7). Ultimately, 7 of the 20 plugs that were inserted were successful, resulting in an overall success rate of 58%.

low morbidity

an option in patients with rectovaginal fistulas without an associated sphincter defect or associated incontinence.

Bioprosthetics

Bioprosthetic mesh has been used as an interposition graft to repair rectovaginal fistulas.

In a group of 27 women with rectovaginal fistulas who

underwent advancement flap and placement of an interposition graft of bioprosthetic material, there were 5 recurrences (19%).

The recurrence rate was lower than women who underwent advancement flap repair without mesh (34%);

Only non randomized studies

TISSUE INTERPOSITION PROCEDURES

Interposition of normal well-vascularized healthy tissue between suture lines.

most commonly used are the bulbocavernosus muscle and gracilis muscle.

This technique was first described by Martius in 1928 and was originally used for the repair of vesicovaginal fistulas;

TISSUE INTERPOSITION PROCEDURES

useful for complex fistulas including radiation-induced RVF, large obstetric fistulas, those for which previous repairs have failed, and selected pouch-vaginal fistulas

Using this technique for complex fistulas, Pinedo and Phillips reported healing in 6 of 8 patients

Bulbocavernosus (Martius) flap

lithotomy position,

a mediolateral episiotomy incision The vaginal side of the fistula is mobilized and excised. The rectal side

of the fistula is closed.

Along the opposite labia majora, an incision is made and the bulbocavernosus muscle and labial fat pad are mobilized.

The bulbocavernosus muscle and labial fat pad are brought through a subcutaneous tunnel and secured to the previously closed rectal side of the fistula

The vaginal defect is closed, and the incisions are closed. Drainage is effected with a Penrose or closed-suction drain.

Dyspareunia, infrequently reported as an outcome variable, is a potential concern with the procedure

The gracilis muscle is also used for interposition.

The gracilis is mobilized and brought through a tunnel with care to preserve the neurovascular bundle.

There are five series of 4 to 17 patients with rectovaginal and pouch-vaginal fistulas with an overall healing rate per patient of 50% to 92% and a healing rate per procedure of 47% to 85%.

Despite healing of the fistula in the majority of patients, quality of life and sexual function remained altered, with only 4 of 7 patients who were sexually active after surgery and 25% of patients reporting dyspareunia.

ABDOMINAL PROCEDURES

Complex fistulas are generally not suitable for a local repair

Higher in location than obstetric fistulas

surrounding tissues are abnormal and poorly vascularized Abdominal procedures permit excision of abnormal tissue,

with interposition of well-vascularized normal tissue to correct the fistula

Preservation of the sphincter is possible with such

procedures as coloanal anastomosis and onlay patch anastomosis.

Coloanal Anastomosis

Patients with radiation proctitis and rectovaginal fistula may be treated by resection and coloanal anastomosis

The technique involves proximal loop diversion, rectal resection below the level of the fistula, and mobilization of the left colon.

Although Parks et al described a distal mucosectomy followed by a coloanal anastomosis, a double-staple technique (as is used for the ileoanal pouch procedure) may also be used, and a colonic J-pouch may be added to improve neorectal function.

Coloanal Anastomosis

If available, omentum is interposed between the anastomosis and the vagina.

Using the coloanal anastomosis, Cooke and

Wellsted reported a 93% success rate in 55 patients.

A modification of the coloanal technique has been reported by Simonsen et al, who used the anterior rectal wall to construct a neovagina. The authors reported no operative deaths and no recurrent fistulas in 19 patients.

Onlay Patch Anastomosis

Bricker and Johnston described an alternative approach for radiation-induced rectovaginal fistulas and particularly fistulas that involve large portions of the vagina.

involves mobilization of the rectosigmoid and exposure of

the fistula.

After transection of the rectosigmoid, an end stoma is formed.

Subsequently, the distal rectosigmoid is rotated down, and the open end is anastomosed to the debrided edges of the fistula opening in the rectum.

Onlay Patch Anastomosis

After healing has been confirmed with radiographic studies, the proximal sigmoid is sutured in end-to-side fashion to the loop in the rectosigmoid.

Advantage- posterior rectal mobilization and entry into the presacral space are not necessary

Disadvantage- the diseased rectum is left in place for the

anastomosis Bricker and Johnston reported excellent or satisfactory results

in 19 of 20 patients The procedure is rarely performed in clinical practice

Role of Diversion

poor medical risk and cannot tolerate major surgery, simple fecal diversion with either a loop ileostomy or colostomy may provide good symptomatic relief and return to a reasonable quality of life.

role in patients who have undergone repair of

complex fistulas by coloanal anastomosis or Bricker onlay patch anastomosis

Crohn disease, failed multiple previous local repairs may also benefit from fecal diversion as an adjunct to primary repair or as a primary procedure.

RECTOURETHRAL FISTULAS

Rare

may occur from either congenital or acquired causes

Congenital fistulas are often associated with other anorectal abnormalities

acquired fistulas may result from trauma,

previous surgery, Crohn disease, infection, malignancy, and/or radiation.

Historically, RUFs occurred after open simple prostatectomy, TURP, perineal prostatectomy, and perineal biopsy of the prostate.

over the past two decades, the detection and treatment

of prostate cancer has exponentially increased

Now the primary cause of RUF are patients of prostate cancer undergoing primary or salvage high-dose brachytherapy, EBRT, cryotherapy, and radical prostatectomy by either an open or laparoscopic/robotic approach

Not only has the incidence of RUF increased with more prostate cancer therapy occurring but the complexity and difficulty of the RUF has shifted dramatically

Before 1997, radiation-induced RUF accounted for only 3.8% of all RUFs. Since 1998, the incidence of radiation-induced RUF is 49.6% and growing, reflecting the widespread utilization of radiation therapy for the treatment of prostate cancer.

a shift from predominantly small surgical fistulas with relatively healthy surrounding tissue to more complex fistulas associated with substantial tissue defect, severe fibrosis, unhealthy radiated tissue, and concurrent urethral strictures.

The emergence of large, complex radiated RUFs has mandated a change in surgical technique away from simple fistula closure to patch graft urethral reconstruction with interposition muscle flap or complete prostatectomy.

INCIDENCE OF RUF

Rectal injury is a well-recognized complication of prostate surgery, with RUF occurring in 0.5% to 3.0% of contemporary series.

Patients undergoing ablative brachytherapy, EBRT, or cryotherapy have a reported incidence of 0.2% to 3% for primary therapy and 7% to 9% for combined or salvage therapy.

RUF development (3.7%) also occurs in patients who undergo rectal biopsy after primary ablative therapy.

PRESENTATION AND EVALUATION

passage of urine per rectum, fecaluria, and pneumaturia

Patients who develop fistulas after brachytherapy or cryotherapy may initially complain of severe pain.

Examination and evaluation

examination under anesthesia

retrograde urethrography, voiding cystourethrography, urethrocystoscopy, and digital rectal examination help define the location, size, and extent of the fistula as well as determine if a coexisting urethral stricture or bladder neck contracture is present.

Anoscopy and flexible sigmoidoscopy/colonoscopy identify the rectal opening and assess the anal sphincter and the rectum for evidence of intrinsic rectal disease such as inflammatory bowel disease or radiation proctitis.

TREATMENT OF RUF

the complexity of the fistulas, the status of the surrounding tissues, the size of the defect, and prior radiation therapy determine optimal repair.

Delaying surgery for 3 months with both urinary and fecal diversion remains the mainstay in RUF management

it allows for an attempt at spontaneous resolution, resolve acute infections, decrease inflammation, and optimize tissue for future reconstruction.

In the case of a small surgically induced fistula, without previous radiation, repair without fecal diversion can be considered.

In patients with complex fistulas (size >2 cm, radiated/ ablated, prior failed repair, concomitant pelvic abscess) that will require a patch graft and muscle interposition, fecal diversion is mandatory.

Large fistula defects require interposition of additional tissue, and the gracilis muscle is ideally suited for this technique.

Radiated RUF represents one of the most challenging operative cases because of the inaccessible fibrotic space, with adherent planes creating a challenging dissection and closure of the fistula

The largest series reported 74 patients with RUF comparing nonradiated and radiated/ablation-induced RUF using a single technique.

All RUFs were repaired via an anterior perineal anal sphincter–preserving approach with an interposition muscle flap.

Selective use of a buccal mucosal patch (BMG) for urethral closure.

36 nonradiated and 38 radiated/ablation-induced RUFs were compared. Concurrent urethral strictures were present in 11% of nonradiated

and 29% of radiated/ablated RUFs. At a mean followup of 20 months, 100% of nonradiated RUFs were closed

with one procedure, whereas 84% of radiated/ ablated RUFs were closed in a single stage.

In the nonradiated RUF group, 35 of 36 patients (97%) had reversal of the fecal diversion whereas 1 patient remained diverted because of a devastating rectal injury. 69% of the radiated/ablated RUF patients had bowel continuity reestablished, whereas 31% required permanent fecal diversion.

The anterior perineal approach with muscle interposition and selective use of BMG onlay is considered the optimal approach for successful closure of all RUFs, avoiding cystoprostatectomy and permanent urinary and fecal diversion.

Gracilis muscle flap

Buccal graft patch

Gracilis muscle interposition flap with buccal mucosal patch closure of urethra

Gracilis muscle flap coverage and support of buccal graft and periurethral tissue

York-Mason posterior transanosphincteric approach and endorectal sliding flap.

The York-Mason procedure utilizes a prone jackknife position followed by posterior midline division of the sphincteric muscles for exposure and closure of the RUF. High fistula closure rates have been reported with this approach (85% to 100%).

The advantage of relatively unscarred tissue planes must be balanced against the risk of causing anal dysfunction and an inability to repair large, complex RUFs that cannot be closed primarily.

endorectal sliding flap

Low, simple fistulas may also be repaired by an endorectal sliding flap.

The main advantage of such a repair is minimal morbidity and quick recovery, whereas the main disadvantage of this procedure is that the high-pressure urethral side is not addressed and a period of prolonged catheter drainage is needed.

Using such an approach, initial closure was achieved in 8 (67%) of 12 patients.

summary

Patients with rectourethral fistulas represent a heterogeneous group and consideration for treatment needs to address both rectal and urinary function.

During the past decade, there has been a shift from small fistulas to more complex fistulas associated with substantial tissue defect, fibrotic radiated tissue, and concomitant urethral strictures

modifications in the surgical technique and the use of tissue interposition and fecal diversion in a majority of cases is required.

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Rectovaginal and rectourethral fistulas

Health & Medicine

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