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Background: Treatment of rectovaginal fistulas is difficult, and many surgical interventions have been developed. The best surgical intervention for the closure of these fistulas is still unclear., Objective: A systematic review was performed reporting the outcomes of different surgical techniques for rectovaginal fistulas., Data Sources: Medline (PubMed, Ovid), Embase (Ovid), and The Cochrane Library databases were searched for eligible articles as well as the references of these articles., Study Selection: Two independent reviewers analyzed the search results for eligible articles based on title, abstract, and described results., Intervention(s): Any surgical intervention for the closure of rectovaginal fistulas was included., Main Outcome Measures: The main outcome was closure rate. Secondary outcomes were quality of life, morbidity, and the effect on sexual functioning., Results: Many articles with different operative techniques were identified and classified in the following categories: advancement flaps (endorectal and endovaginal), transperineal closure, Martius procedure, gracilis muscle transposition, rectal resections, transabdominal closure, mesh repair, plugs, endoscopic repairs, closure with biomaterials, and miscellaneous techniques. Results vary widely with closure rates between 0% and >80%. None of the studies were randomized. Because of the poor quality of the identified studies, the comparison of results and performance of a meta-analysis were not possible.Data regarding the secondary outcomes were mostly unavailable., Limitations: The major limitation of this review was the limited availability of high-quality prospective studies, making it impossible to perform a meta-analysis., Conclusions: No conclusion about the best surgical intervention for rectovaginal fistulas could be formulated. More large studies of high quality are needed to find the best treatment for rectovaginal fistulas. A design for these high-quality studies was formulated.

Background: The long-term closure rate of high perianal fistulas after surgical treatment remains disappointing., Objective: The goal of this study was to improve the long-term closure rate of high cryptoglandular perianal fistulas combining mucosal advancement flap with platelet-rich plasma., Design: This study was retrospective in design., Setting: This study was conducted at 2 secondary and 1 tertiary referral hospitals., Patients: Patients presenting with high cryptoglandular perianal fistulas involving the middle/upper third of the anal sphincter complex were included., Interventions: A staged surgical treatment was performed; After seton placement, a mucosal advancement flap was combined with platelet-rich plasma., Main Outcome Measures: Recurrence was the main outcome. Incontinence was the secondary outcome., Results: We operated on 25 patients between 2006 and 2012. Thirteen (52%) patients had previous fistula surgery. The median follow-up period was 27 months. One patient (4.0%) was lost to follow-up after 4 months. Freedom from recurrence at 2 years was 0.83 (95% CI, 0.62-0.93). Two of the 4 patients with a recurrence (8%) had a repeated treatment and healed. One patient (4.0%) refused another treatment, but agreed to stay in follow-up. One patient (4.0%) requested a colostomy, resulting in closure of the fistula. Complications occurred in 1 patient (4.0%). Incontinence numbers were low with a median Vaizey score of 3.0 out of a maximum of 24., Limitations: The study was limited by its retrospective design, lack of preoperative incontinence data, selection bias, and phone interview follow-up., Conclusion: The long-term outcome results of patients with primary and recurrent high cryptoglandular perianal fistulas treated with a seton followed by mucosal advancement flap and platelet-rich plasma show low recurrence, complication, and incontinence rates. Therefore, this technique seems to be a valid option as treatment. Larger and preferably randomized controlled studies are needed to further explore this surgical technique.