ANAL-SPHINCTER INTEGRITY AND FUNCTION INFLUENCES OUTCOME IN RECTOVAGINAL FISTULA REPAIR

PURPOSE: Traumatic sphincter disruption frequently is associated with a rectovaginal fistula, but the effect of a persistent sphincter defec t on the outcome of rectovaginal fistula repair is poorly documented. We analyzed the outcome of rectovaginal fistula repairs based on preop erative sphincter status. PATIENTS AND METHODS: We identified 52 women who underwent 62 repairs of simple obstetrical rectovaginal fistulas between 1992 and 1995. Fourteen patients (27 percent) had preoperative endoanal ultrasound studies and 25 (48 percent) had anal manometry st udies. Follow-up was by mailed questionnaire in 36 patients (69 percen t) and by telephone interview in 12(23 percent), for a total response rate of 92 percent. Median age was 30.5 (range, 18-70) years, and medi an follow-up was 15 (range, 0.5-123) months. Twenty-five patients (48 percent) complained of varying degrees of fecal incontinence before su rgery. There were 27 endorectal advancement flaps and 35 sphincteropla sties (28 with and 8 without levatoroplasty). RESULTS: Success rates w ere 41 percent with endorectal advancement flaps and 80 percent with s phincteroplasties (96 percent success with and 33 percent without leva toroplasty; P = 0.0001). Endorectal advancement flap was successful in 50 percent of patients with normal sphincter function but in only 33 percent of patients with abnormal sphincter function(P = not significa nt). For sphincteroplasties, success rates were 73 vs. 84 percent for normal and abnormal sphincter function, respectively (P = not signific ant). Results were better after sphincteroplasties vs. endorectal adva ncement flaps in patients with sphincter defects identified by endoana l ultrasound (88 vs 33 percent; P = not significant) and by manometry (86 vs. 33 percent: P = not significant). Poor results correlated with Drier surgery in patients undergoing endorectal advancement flaps (45 percent vs. 25 percent; P = not significant) but not sphincteroplasti es (80 vs. 75 percent; P = not significant). CONCLUSIONS: AU patients with rectovaginal fistula should undergo preoperative evaluation for o ccult sphincter defects by endoanal ultrasound or anal manometry or bo th procedures. Local tissues are inadequate for endorectal advancement flap repairs in patients with sphincter defects and a history of prev ious repairs. Patients with clinical or anatomic sphincter defects sho uld be treated by sphincteroplasty with levatoroplasty.