Before going to the management, I will be talking a little bit about the epidemiology. First, we have to know what is the difference between anal incontinence, fecal incontinence and the rectal vaginal fistula. Anal incontinence is the involuntary loss of lattice, liquid or solid, that is perceived as a social or hygienic problem. And fecal incontinence is just the involuntary loss of liquid or solid stool only. And rectal vaginal fistula, it is the epithelial communication between the rectum and the vagina. And it may present either with the fecal incontinence or the anal incontinence. And mostly the anal incontinence. And as we know, rectal vaginal fistula is usually associated with the sacral vaginal fistula as well. And isolated VVF in 85% of the patients and in 10 to 15% of the patients, we have both VVF and RVF. And isolated RVF is very rare, except for the ischemic anion rupture with distal rectum trauma. In BBKHS also, among the total genital fistula, rectal vaginal fistula represents about 8 to 10%. Coming to the causes, mostly, as I have already discussed, that mostly we are getting obstetric and the most common cause is also obstetric, with different causes like obstructed liver, instrument of delivery, shoulder dystocia, and especially the midline epiglottomy, which is not practiced in our country, but in some countries, midline epiglottomy is practiced. And another important cause after the obstetric is the iatrogenic, mostly the stectomies, and either abdominal or vaginal stectomy, and hemorrhoidectomy, posterior repairs, and different types of surgery can lead to the rectal vaginal fistula. Other rare causes like inflammatory bowel disease, infections, and of course, different carcinomas like cervical carcinoma, rectal carcinomas, and vaginal carcinomas may lead to the rectal vaginal fistula. And the last one is radiation-induced. Before going to the management, I want to show some pictures that we come across in our institute. You can see the rectal vaginal fistula, along with the vesicle vaginal fistula in the first picture. And in the second picture, you can see the repaired one, and epiglottomy is given. Usually, epiglottomy is not required for the management of the rectal vaginal fistula, but for the exposure of the vesicle vaginal and the repair also, and it may be needed, but that is not mandatory. This is the most common type of the rectal vaginal fistula that we come across, that is, spiritual rupture, along with the rectal mucosa also, that is, damage of the rectal mucosa as well. And the second one is the repaired one. Sometimes, we may confuse with this type of presentation, and we may think that this is a normal one, and we can see the skin tags, but they are also usually associated with the spinae rupture and the rectal vaginal fistula. And so, now we have to be cautious when we see this type of the presentation in the patient. This is the case that we just operated a few days back, and then she's case of the, like Dr. Poonam presented, she was in case of chemo radiation, and she presented was with sigmoid vaginal fistula. And then, we have done the eyelid conduit and the colostomy as well. That's the repaired one, and she's in our post-op ward till now. Now, coming to the clinical evaluation, usually the history suggests the underlying cause, because there is a distinct cause for the rectal vaginal fistula, like it can be just after the obstetric, like deliveries, or different surgeries, or like radiation. There is distinct history of the cause leading to the rectal vaginal fistula. Usually, on physical examination, you can locate where the fistula is, what is the size, what is the number of the openings. And sometimes, it may be difficult to visualize the rectal vaginal fistula due to the staring or due to the small size. And sometimes you need, like in the figure I have shown, you may see that a small probe may be needed to be inserted either through the anal canal or through the vagina. And if there is a fistula strapped, then we can see, as shown in the figure. Sometimes, even with that, it may be difficult to visualize the rectal vaginal fistula. We may need to do diet test or different contrasting studies. Sometimes, perinatal ultrasound and MRI may also be needed to visualize the rectal vaginal fistula, which may be high, or which may be like intestinal fistulas, as I have shown in the previous slides. Before going to the management, I just want to highlight on this picture that anal continence mechanism is maintained by the, mostly by the axonalis major, interanus major, and the puborectalis muscle. Puborectalis muscle, it has a role in maintenance of the anorectal angle, and the interanus major has a role in constant continence in the rest, and axonalis major has a role in stress conditions, or it has fast twitch fibers, which has a role in the maintenance of continence as well. As Poonam has said, there are different ways of classification, and different people have tried in different classifications, and as she has presented, this is the old classifications that we classify like low, mid, and high. Like, if it is low, then it is near the posterior facet, or near the hymen, and if it is high, the fistula is above the level of the cervix, and if it is mid, it is just between the cervix and the hymen, and we call it as mid. But recently, there is a great surgeon whose fistula is Valdik, and he has classified the rectal anal fistula according to the anatomic and physiological location, so it can be easier in follow-up, and like in the research setting also, he has classified it like type 1, type 2, and type 3. Type 1 is proximal fistula, and for this anatomical location, he has taken the pectinate line as the landmark, and called it as proximal or distal, and type 1 also further differentiated with A, B, and C, with rectum structure, without rectum structure, with rectum structure, and type 1 sees circumferential defect, that is, circumferentially, there is a defect between the either rectum and anal canal, or rectum and the sigmoid. Type 2 fistulas, these are the most common fistulas. Usually, the obstetric fistulas are also like these type 2 fistulas, maybe associated with spiroidinal involvement, or without spiroidinal involvement also, and type 3 fistulas are like high deuterium fistulas, colobaginal fistulas, these are the type 3 fistulas, and mostly the radiation fistula, or any complexion associated with the, sometimes with the procedures like abortion procedures may lead to this type of fistulas. It can be classified according to size also, and it can be small, medium, large, and extensive. If it is less than 2 centimeters, it is small, and if it is 2 to 3, it is medium, and 4 to 5 is large, and if it is more than 6 centimeters, that is extensive. Now, coming to the principles, always in the fistula surgery, principle of fistula surgery is similar in both sacrovaginal and rectovaginal fistula. Good positioning with good exposure is the prime, and then in all the fistulas, water tight, tension-free closure is required in rectovaginal fistula also, that it applies. Principally, if fistula is type 1, we close transversely, and if it is type 2 fistula, then we close it longitudinally, and for type 1c, which was, which I already call it as circumferential, type 1c is circumferential fistula, and if it is type 3 fistulas, colobaginal fistulas, and other fistulas are approached abdominally, as in the figure, the transverse closure of the rectal mucosa is seen. And, I just want to focus that most of the fistulas, most of the fistulas are, the approach is vaginal, vaginal, except for the circumferential fistula, and the type 3, like colobaginal fistula, like sigmoidal vaginal fistula, it needs abdominal exposure, but except them, I think we should approach for the vaginal approach, and lithotomy position, we should position the patient in lithotomy, and sometimes in the high, high rectovaginal fistula, extended lithotomy position, like in the second picture, the anal buttock is at the edge of the table, and then the position of the hip, that is more flexion of the hip, with a slight external rotation, and that is extended lithotomy position may be needed for the high rectovaginal fistula repair. And for the preoperative, we give tinirazole, and the products become antibiotics. For any repair, postoperative care is very important. In the rectovaginal fistula, there are certain things that we should focus on, like previously, it used to be said that, that hourly, that we should not allow a patient to eat, but recent studies have shown that hourly feeding is equally as good as late feeding. And therefore, in our practice, we are practicing that we are not allowing patients to have meal per oral for like four, five days, or 10 days also, because previously, different surgeons, they used to practice that they don't allow patients to eat solid food for like 10 days, 12 days, but the things are changing. And Follies catheterization also, there is controversy regarding Follies catheterization, some say that early removal is okay, and some say that it needs to be good for like five, seven days, but there is no any clear-cut guideline that it should be, Follies catheterization should be kept for the longer period. And in our practice also, we are like, we are practicing for prolonged Follies catheterization. We insert Follies catheterization until patient pass the stool. The only thing is that we should not allow a patient to strain on defecation, so like in the food or in the Follies catheter, we don't allow patient to constipate, so that there is straining on the suture side, and maybe associated with failure rate as well. And we don't prescribe any other antibiotics, no antibiotics, only on the strict indication like pneumonia or any other findings, like you know, tract infection, we may prescribe antibiotics. Other than that, we don't prescribe antibiotics on the post-operative period, and usually no seizure baths, especially when the spleen and eye has been repaired. Regarding the fix of spleen and cells, so there is controversy whether she should go for normal vaginal delivery or the seizure injection. Most of the literature says that she should undergo supervised pregnancy in the hospital delivery. Now coming to the radiation induced fistula, as Dr. Poonam has said, it can be due to either radiation injury to the tissues, or it may be simply only because of the destruction of the cat cinema. If it is early, then it is usually due to destruction of the cat cinema, and if it is late, then it is usually related to the radiation injury to the tissues, like as already said by the different speakers, it may be related to the blood supply, vascular supply of the tissues. And usually it is seen within two years, but as Dr. Poonam has said, it can be seen as late as 10-15 years as well. Usually in the late, it usually begins with the prokaryotes with ulceration, because of the vascular supply ulceration and later fistula formation. And usually it is associated with the stricture and significant pediatric fibrosis and scarring due to the radiation. And these radiation fistulas are located high in the posterior vaginal wall, usually mid to high type. If the patient is present with the colorectal bleeding, non-healing ulcers and anorectal pain, we should be cautious regarding the development of the rectal vaginal fistulas. Now coming to the repair of the radiation in these fistulas, of course it is challenging. There is controversy regarding the vaginal or abdominal route, and still we believe that vaginal route should be the preferred route for the repair of the rectal vaginal fistula. If it is rectal vaginal fistula, except for the circumferential and the colobaginal fistula, where you cannot access vaginally. Other than that, vaginal route should be the route of the choice. Since successful closure of the fistula requires, because it is associated with the stricture and periodontal fibrosis as well, it requires aggressive accession of the surrounding tissue. So there will be large defects. So surgeons who are dealing with these fistulas, they should have knowledge regarding the different grafts, like macia scraped, as Dr. Poonam has also said, macia scraped and gracilis scraped. And we are in BBKGIS, we are practicing at the Singapore lab for different other procedures as well, for vaginal reconstruction surgeries. And this is a very good way of using the graft for this type of the fistulas, because it is a large graft, large defect in the rectum. In the first figure, this is the periodontal high flap graft that we can use for the rectal vaginal fistulas. And this is a picture taken from our patient as well, where we have used this graft, bilateral periodontal thigh flap. Especially this is for the vesicular vaginal fistula, but this flap can be used for the rectal vaginal fistula as well. And second figure is for the macia scraped, we can use that labial flap with the bulbar gavacosis flap for the rectal vaginal fistula. And third one is the gracilis muscle, we can harvest this gracilis muscle and use as a graft in the rectal vaginal fistula. We have not practiced this, but we are usually practicing the periodontal thigh flap and sometimes the macia scraped. I just want to give a quote of one study. This is an old study, even though it is a study done by Rickard C. Borono, where he has seen 22 different radiation fistulas. He has quoted that successful closure was accomplished in 84.2% of the rectal vaginal fistula and 50% of the vesicular vaginal fistula. You can see more than 84% of the rectal vaginal fistula appeared and no patient with the rectal vaginal fistula closure required subsequent colostomy for restriction. But he has not mentioned whether there was associated any other colobaginal fistulas or not. But most of the rectal vaginal fistulas, their closure is possible. Coming to the sigmoidal vaginal fistula, this is the figure that I have already described in the beginning also. This is the patient after the chemoradiation of the CS cervix, which she presented after two months of the chemoradiation, I think. And then she has both large gap, large defect in the bladder, like six to seven centimeter gap defect in the bladder. And there is a defect in the sigmoid as well. We cannot see any defect in the rectum through digital examination. And then we cannot see. And there was like a growth like a structure in the fistula margin as well. And then we did a ileal concrete and then the colostomy as well. It is real, but the overall majority results from the diabetic colitis of the sigmoid colon. Passage of the fecal material or gas through the vagina in the absence of the rectal communication. Then that is the sigmoidal vaginal fistula. For the surgeries of the rectal fistula, sigmoid resection with primary anastomosis and closure of the opening into the vagina. Or sometimes only closure of the sigmoidal defect is sufficient. And sometimes rectal mobilization with colon anastomosis may be required. Is colostomy required in all the fashions of radiation in this fistula? Maybe, absolutely. If it is radiotherapy induced and it is colobaginal fistula, then it may be the choice. And we should always do colostomy if there is circumferential rectal vaginal fistula. And relatively, if there are multiple failed repairs of the rectal vaginal fistula. If we are using like different flaps and we are suspecting of the, so like if there is a, we don't want it to be failed flaps, we can use colostomy. And if it is extensive rectal anastomosis with large defects, then maybe colostomy may be helpful. With this, I would like to conclude my presentation. And I would also like to request if there are, as Dr. Jitendra has said, if there are any fistula like, we have experience of doing it vaginally and maybe patient can benefit from that as well. Thank you, Dr. Jitendra. Thank you, everybody.

recto-vaginal fistulas

anal incontinence

fecal incontinence

causes

treatment approaches

postoperative care