Recto-Neovaginal Fistula Following Vaginoplasty for Vaginal Agenesis: Our Experience and Management Guidelines

Recto-neovaginal fistula is an abnormal communication formed between the rectum and newly formed vagina, following vaginoplasty for vaginal agenesis. It results in soiling of neovagina by fecal matter and inflicts great deal of physical, social and psychological handicap on the sufferer and is one of the most dehumanizing conditions that affect women. The aim of this study was to review our experience in the management of this rare but debilitating condition with emphasis on treatment of fistula, maintaining the neovagina and to present guidelines for the management of this rare and devastating complication. This prospective study was undertaken from June 2007 to September 2011 at the Department of General Surgery, Obstetrics and Gynaecology. Six patients of recto-neovaginal fistula were included, which resulted as a consequence of operative trauma to the rectum during vaginoplasty for vaginal agenesis. Diverting colostomy was made in all cases. After 8-12 weeks definitive repair was done using Gracilis muscle transposition technique. All 6 cases reported complete healing of the fistula as evidenced by absence of fecal matter leakage and preservation of adequate vaginal length. No case had neovaginal stenosis or contracture. After colostomy closure at 4 weeks no patient had neovaginal graft loss or dimensional compromise. The anal sphincter was preserved in all patients. Our study is the largest series of recto-neovaginal fistula repair after Abbe-McIndoe vaginoplasty and has tried to reach a general guideline for their management without neovaginal compromise by providing vascularized gracilis muscle between the rectum and neovagina, expediting the healing of the fistula, and providing a mould to prevent its obliteration while maintaining bulk of the neovagina.