Rectovaginal Fistulas Not Involving the Rectovaginal Septum Should Be Treated Like Anal Fistulas: A New Concept and Proposal for a Reclassification of Rectovaginal Fistulas

Abstract

Pankaj Garg,1 Laxmikant Ladukar,2 Vipul D Yagnik,3 Kaushik Bhattacharya,4 Gurleen Kaur5 1Department of Colorectal Surgery, Garg Fistula Research Institute (GFRI), Panchkula, Haryana, India; 2Department of Surgery, Ladukar Surgical Hospital, Bramhapuri, Maharashtra, India; 3Department of Surgery, Banas Medical College and Research Institute, Palanpur, Gujarat, India; 4Department of Surgery, MGM Medical College and LSK Hospital, Kishanganj, Bihar, India; 5Department of Pharmacology, Adesh Medical College and Hospital, Shahbad, Haryana, IndiaCorrespondence: Pankaj Garg, Chief Colorectal Surgeon, Colorectal Surgery, Garg Fistula Research Institute (GFRI), 1042, Sector-15, Panchkula, Haryana, 134113, India, Email [email protected]: Many rectovaginal fistulas(RVF), especially low RVF, do not involve/penetrate the RV-septum, but due to lack of proper nomenclature, such fistulas are also managed like RVF (undertaking repair of RV-septum) and inadvertently lead to the formation of a high RVF (involving RV-septum) in many cases. Therefore, REctovaginal Fistulas, Not Involving the Rectovaginal Septum, should be Treated like Anal fistulas(RENISTA) to prevent any risk of injury to the RV septum. This concept(RENISTA) was tested in this study.Methods: RVFs not involving RV-septum were managed like anal fistulas, and the RV-septum was not cut/incised. MRI, objective incontinence scoring, and anal manometry were done preoperatively and postoperatively. High RVF (involving RV-septum) were excluded.Results: Twenty-seven patients with low RVF (not involving RV-septum) were operated like anal fistula[age:35.2± 9.2 years, median follow-up-15 months (3– 36 months)]. 19/27 were low fistula[ 1/3 EAS involved) and underwent a sphincter-sparing procedure. Three patients were excluded. The fistula healed well in 22/24 (91.7%) patients and did not heal in 2/24 (8.3%). The healing was confirmed on MRI, and there was no significant change in mean incontinence scores and anal pressures on tonometry. RV-septum injury did not occur in any patient.Conclusions: RVF not involving RV-septum were managed like anal fistulas with a high cure rate and no significant change in continence. RV-septum injury or formation of RVF with septum involvement did not occur in any patient. The RENISTA concept was validated in the present study. A new classification was developed to prevent any inadvertent injury to the RV-septum.Keywords: rectovaginal, fistula, anal, incontinence, recurrence, scoring system, fistulotomy, classification

Keywords

• rectovaginal
• fistula
• anal
• incontinence
• recurrence
• scoring system
• fistulotomy
• classification