Muscle Interposition in Patients with Fistulas Between the Rectum and Urethra or Vagina

To the Editor—We have read with great interest the article by Zmora et al. concerning gracilis muscle interposition for surgical repair of a rectovaginal or rectourethral fistula. In the past, several techniques have been described for the treatment of these fistulas, often with rather disappointing results. It has been suggested that interposition of healthy, well-vascularized tissue may be the key to rectovaginal fistula healing. Zmora et al. performed gracilis muscle interposition in nine patients with a rectovaginal or rectourethral fistula. All patients underwent fecal diversion before or at the time of the procedure. In seven patients, the fistula healed after gracilis muscle interposition at a median follow-up time of 14 months after stoma closure. In a recent study conducted in our institution, we encountered a rather disappointing low overall healing rate of 62 percent in 26 females who underwent puborectal sling interposition for the treatment of their rectovaginal fistula. The median duration of follow-up was 14 months. In all but one patient this procedure was performed without covering ileostomy. The question is whether such a covering ileostomy should be created in all patients undergoing rectovaginal fistula repair. It has been reported that a successful outcome can be achieved without the use of a protecting stoma. It is difficult to determine whether fecal diversion ameliorates the outcome, because fecal diversion often is used in the most difficult cases. Another aspect of muscle interposition is the risk of postoperative dyspareunia. In our study, 57 percent of the females without painful intercourse before the operation reported painful intercourse after the procedure. It is not clear whether Zmora et al. encountered this side effect of muscle interposition. Because postoperative dyspareunia has a substantial influence on quality of life, more studies are warranted to investigate the incidence of dyspareunia after muscle interposition.