Radiation-induced Rectovaginal Fistula Surgical Treatment: a Case Report

Background: Radiation-induced rectovaginal fistula (RI-RVF) is a serious complication of radiation therapy for pelvic malignancies. We present here a new surgical approach which aims at decreasing recurrence rates by avoiding radiated tissue in the reconstruction. Case Description: We report a case of a 58-year-old female with a remote history of hystero-salpingooophorectomy with postoperative pelvic radiation. Rectosigmoid perforation accompanied by peritonitis occurred after the first chemotherapy infusion for a recent diagnosis of stage 3 Hodgkin's lymphoma, necessitating emergency rectosigmoid resection with end colostomy. During follow-up, the patient developed a RVF and rectal stricture at 7 cm from the anal verge. The patient underwent a combined repair with Tuttle transvaginal access, Turnbull-Cutait pull-through, and a Singapore flap as follows: (I) following rectal dissection achieved through a longitudinal incision of the posterior vaginal wall, low anterior resection of rectum was performed via laparotomy; (II) the descending colon was pulled through trans-anally with subsequent delayed handsewn coloanal anastomosis at 2 weeks; (III) the posterior vaginal wall was bridgeclosed with a Singapore flap. The postoperative recovery was uneventful, and the loop ileostomy was reversed without complications. Following a 6-month period, any to eliminate recurrence was documented. Conclusions: A combined repair via a Tuttle transvaginal access with a Turnbull-Cutait colon pullthrough and Singapore flap can be an effective approach in cases where tissue healing is compromised due to prior radiation therapy.