Sphincter repair procedures may be favored in the treatment of obstetrical recto-vaginal fistula: a systematic review of the literature and meta-analysis

TL;DR

This study compares surgical procedures for repairing obstetric rectovaginal fistulas and finds that sphincter repair methods may be more effective than others.

Contribution

The study provides a systematic review and network meta-analysis comparing the success rates of various surgical techniques for obstetric rectovaginal fistula repair.

Findings

The Musset procedure, transvaginal ELC, and transperineal ELC showed significantly better anatomical results compared to ERAF.

Most patients underwent ERAF or ELC, but the overall quality of the studies was low due to lack of randomization.

Further randomized trials are needed to compare anatomical and functional outcomes of different procedures.

Abstract

The management of obstetric rectovaginal fistula (RVF) is challenging for the surgeon. The best surgical procedure to repair RVFs, specifically after obstetric anal sphincter injury, has not been extensively studied. The objective was to compare the success of the different procedures performed to repair obstetric RVF.

The literature search was carried out on PubMed® and Web of Science® from database inception until 31 December 2022. Selection criteria were: (1) patients with a diagnosis of obstetric-related RVF; (2) patients treated surgically with no restriction concerning the considered surgery; (3) clinical trials or epidemiological studies. Meta-analysis was conducted considering the network meta-analysis framework to allow studying the relative value of each treatment mentioned in the selected articles.

The quantitative synthesis included 32 studies (18 retrospective and 14 prospective) accounting for 595 patients. The quality of these studies was low because of the lack of prospective randomization. Nineteen procedure types were described and assessed. Most patients (n = 180) underwent endorectal advancement flap (ERAF) followed by excision and layered closure (ELC) (n = 213) and Musset procedure (n = 65). A diverting stoma was performed in 66/132 patients. Only 13 studies reported the functional results of the procedure. In the meta-analysis, the Musset procedure (OR = 4.29; 95% CI: 1.18–16.14), transvaginal ELC (OR = 11.84; 95% CI: 2.18–91.80) and transperineal ELC (OR = 3.56; 95% CI: 1.26–10) significantly improved the anatomical results compared to ERAF.

A further randomized controlled trial in the literature assessing ERAF and sphincteroplasty to compare the anatomical results, functional results and morbidity of this treatment is needed.

PROSPERO CRD42023447875.

The online version contains supplementary material available at 10.1007/s10151-025-03133-3.

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