Treatment Strategy for Post-Obstetric Rectovaginal Fistula without Requiring Diverting Stoma: A Retrospective Analysis of 46 Cases Demonstrating the Superiority of Our Institution's Original Technique.

Background: Post-obstetric rectovaginal fistula significantly impairs women's quality of life, and the indication for diverting stoma creation remains controversial. Despite numerous international reports indicating that diverting the stoma is unnecessary for post-obstetric rectovaginal fistula, many institutions continue to perform stoma creation in clinical practice. Methods: We retrospectively analyzed 46 cases of post-obstetric rectovaginal fistula treated with perineal body reconstruction over 3 years. Patient demographics, fistula characteristics, treatment history at other institutions, surgical outcomes, and postoperative course were evaluated. The primary outcome was the absence of fistula recurrence during a 12-month follow-up period. Results: The median age was 34 years, the median body mass index was 21, the median fistula size was 2 mm, and the median duration from onset to surgery was 268 days. The majority of cases involved severe obstetric trauma with grade 4 perineal lacerations. Seven patients (15.2%) were recommended stoma creation at other institutions, and a total of 15 surgeries were performed at other institutions. Stable surgical outcomes were achieved with a median operative time of 130 minutes and a median blood loss of 250 mL. During the 12-month follow-up period, favorable results were obtained in 44 cases (95.7%), with one missed concomitant high fistula subsequently treated successfully via a transvaginal approach, and one suspected recurrence reported by telephone at 24 months (after completion of follow-up) without clinical confirmation. Conclusions: Our institution's original perineal body reconstruction technique achieved a high cure rate without requiring a diverting stoma creation. Typical post-obstetric rectovaginal fistulas develop at the lowest point where rectal pressure is highest, making perineal body reconstruction effective for the majority of cases. However, in patients with extensive perineal laceration scarring on digital rectal examination, preoperative fistulography should be considered to rule out concomitant high fistulas. Diverting stoma creation for post-obstetric rectovaginal fistula is generally unnecessary.