Skip to main content

Fecal Diversion in Reconstructive Pelvic Surgery

Fecal diversion can control contamination, support a staged repair, or provide definitive symptom relief. Its role differs between pelvic fistulae, necrotizing infection, traumatic wounds and fecal incontinence (FI). Discuss the intended benefit, stoma care and possibility of permanent diversion before an elective procedure.[1][2][3]

Fistula closure, continence, symptom relief and stoma reversal are different outcomes. A successful reconstruction may still leave a patient with a stoma or functional impairment. Comparisons between diverted and nondiverted patients are strongly affected by case selection.

Indications and Evidence​

Rectovaginal Fistula​

Diversion is individualized according to sepsis, symptoms, tissue injury, prior repair and the proposed reconstruction. ASCRS supports considering it with complex repairs; its additional benefit with an advancement flap is not established. For anastomotic RVF, diversion may be an initial measure: the often-quoted 37% closure with diversion alone came from 6 of 16 patients in one series, not a general cure probability.[1]

StudyWhat the comparison actually shows
Obi 2026: 158 patients, 424 procedures100 patients had diversion and 58 did not. Prior repairs and interposition flaps were more common with diversion; healing/recurrence differences were not statistically significant. This does not establish equivalence or prove that diversion equalizes risk.[4]
Fu 2019: 63 patients, 80 local repairsOverall closure did not differ by diversion. Among 15 patients requiring repeat operations at that center, 10/12 with a stoma healed versus 0/3 without. This small, nonrandomized subgroup does not mandate a stoma after every failed repair.[5]
Corte 2015: 79 patients, 286 proceduresDiversion was associated with per-procedure success (adjusted OR 3.5, 95% CI 1.4–8.7) in a mixed-etiology cohort; this was not a Crohn's-specific estimate or a randomized effect.[7]

Radiation-associated RVF may require long-term diversion, reconstruction or proctectomy according to tissue viability, symptoms and fitness. Diversion can relieve symptoms without closing the tract. A retrospective comparison of 28 laparoscopic and 38 open colostomies reported shorter stay and fewer surgical-site infections with laparoscopy; selection and operative anatomy limit causal interpretation.[1][6]

Rectourethral Fistula​

Urinary drainage and fecal diversion are separate decisions. In Beddy's 50-patient cohort, 30 had fecal diversion and 37 urinary diversion before definitive surgery; these were not necessarily the same patients.[8]

Prior radiation or ablation raises reconstructive difficulty and the chance of permanent diversion. It does not mean that every irradiated patient has an unreconstructable outlet:

Selected seriesRelevant outcome
Vanni 2010, 74 transperineal repairs with muscle interpositionSingle-stage closure: 35/35 nonirradiated versus 84% of 39 irradiated/ablated patients. Permanent fecal diversion was required in 31% of the latter group.[9]
Hanna 2014, 37 patientsOstomy reversal: 55% in the irradiated group versus 91% without irradiation.[10]
Linder 2013, 45 patientsAmong 29 irradiated/ablated patients, 25 ultimately required permanent colostomy and 27 urinary diversion. Only six underwent attempted primary repair, with one successful repair.[11]
Martins 2021, 23 patientsClosure after reconstruction: 5/10 radiation/ablation versus 13/13 surgery-only; permanent dual diversion occurred in half of the radiation/ablation group.[12]

These different referral populations and treatments cannot be combined into a universal radiation failure rate. The Lo Re systematic review (10 studies, over 500 patients) found transperineal gracilis interposition most commonly reported and worse outcomes after irradiation, while emphasizing the lack of standardized comparative evidence.[13]

Complex Entero-Urinary Fistulae​

Control sepsis, drain both systems as needed, restore nutrition and plan reconstruction jointly with colorectal and urologic surgeons. Shackley's historical 10-patient referral series achieved fistula control in all patients, but only four had functional restoration; six required gastrointestinal and/or urinary diversion. The mean five-month interval to reconstruction was a cohort observation, not a required waiting period.[3]

Fournier's Gangrene and Perineal Wounds​

Urgent debridement, resuscitation and antibiotics take priority. Consider colostomy for sphincter damage, uncontrolled fecal contamination or inability to manage the wound. WSES-AAST recommends a tailored multidisciplinary approach. Its discussion of observing for 48 hours before deciding on a stoma comes from a retrospective report; it is not a rule to defer necessary source control.[16]

Reported utilization varies: Ortega's 149-patient series used 32 colostomies and 18 rectal collection devices, whereas a US inpatient analysis recorded fecal diversion in 4.68% of cases. Neither proportion measures permanent stoma risk.[14][15] A 27-study meta-analysis involving 1,482 patients associated stoma formation with greater mortality (OR 1.71, 95% CI 1.13–2.59); confounding by severity and sphincter injury prevents concluding that diversion causes death or should be withheld.[17] Potential wound-care benefits are described mainly in observational reports and narrative reviews.[18]

For perineal trauma, assess the actual bowel and sphincter injury. Kudsk's 2003 combined-treatment series does not isolate the benefit of diversion or justify routine distal rectal washout.[19] EAST's guideline for nondestructive penetrating extraperitoneal rectal injury conditionally supports proximal diversion and advises against routine distal washout and presacral drainage; this specific recommendation is not a protocol for every perineal wound.[29]

Fecal Incontinence​

ASCRS considers colostomy an option when other therapies have failed or the patient does not wish to pursue them. It need not follow an obligatory trial of every device or operation. Assess preferences, alternative treatments, surgical fitness and support for appliance care with the appropriate specialist team.[21][22] In a survey of 69 patients cited by ASCRS, 83% reported lifestyle improvement and 84% would choose the stoma again. These are respondent outcomes, not guaranteed benefits.[21]

Choosing a Diversion​

OptionMain considerations
Loop ileostomyOften reversible; high-output losses, dehydration and kidney injury risk require particular attention. Generally less prolapse than loop colostomy.[24]
Loop colostomyAlso effective for temporary diversion; generally less dehydration but more prolapse. Choose the site and segment in relation to bowel disease and future reconstruction.[24]
End colostomyMay be temporary or permanent. Reversibility depends on the remaining distal bowel, sphincter, operation and patient fitness; after anorectal excision there is no distal outlet to restore.[24]
Rectal collection deviceShort-term containment of liquid stool in selected adults; does not provide the same protection as a surgical diversion and may be contraindicated in the very injuries requiring reconstruction.[28]

ASCRS 2022 regards both loop ileostomy and loop colostomy as effective (strong recommendation, moderate-quality evidence); neither is universally preferred.[24]

Arndt 2026: a single-center retrospective cohort of 306 ileostomies and 209 colostomies reported stoma-related readmission in 23% versus 13%, respectively (adjusted OR for ileostomy 3.15, 95% CI 1.76–5.65). Dehydration accounted for 60% versus 11% of readmissions—not of all patients. Pouching problems were more frequent with ileostomy (68% versus 43%); prolapse (4% versus 16%) and revision (4% versus 12%) were more frequent with colostomy. These are counseling data, not proof of superiority for a particular fistula.[23]

Rectal Device Safety​

Small wound-care reports describe successful use, including two cases involving a sacral pressure injury and perianal burns; they do not establish safety after fistula repair or rectal trauma.[20]

For Flexi-Seal PROTECT PLUS, the manufacturer limits use to adult liquid/semi-liquid stool and no more than 29 consecutive days. Contraindications include rectal surgery within one year, rectal/anal injury, significant hemorrhoids, mucosal impairment, stricture and suspected rectal/anal tumor. Bleeding risk and spinal cord injury require additional caution. Monitor for pain, bleeding, obstruction and pressure injury; remove the device promptly for rectal bleeding. Follow the exact device instructions, not a generic “try Flexi-Seal first” rule.[28]

Reversal, Complications and Follow-up​

Record separately whether reversal was attempted, completed and sustained. Healing of the fistula alone does not ensure a useful, safe distal bowel or adequate continence. Discuss non-reversal before creating a nominally temporary stoma.

  • Severe perianal Crohn's disease: Becker's 53-patient cohort had 11 reversal attempts and nine successful closures; 35% required proctectomy/proctocolectomy. Clinical fistula closure was reported in 26%. These results concern therapy-refractory perianal disease, not isolated RVF or all Crohn's patients.[25]
  • Fournier's: in Rosen's series, six patients received a new colostomy; two underwent reversal, two were medically unfit and two were lost to follow-up. This cannot yield a reliable permanent-stoma percentage.[26]
  • Creation and maintenance: monitor skin, output, hydration, renal function when losses are significant, retraction, prolapse and parastomal hernia. Provide preoperative marking when feasible and ostomy-nurse education.[24]
  • Closure: counsel about infection, ileus, leak and incisional hernia. A 2024 Cochrane review of nine randomized trials (757 participants) found that purse-string skin closure probably reduces SSI versus linear closure (OR 0.17, 95% CI 0.09–0.29; moderate certainty). This is skin-closure evidence, not evidence about fistula closure or when to reverse.[27]

Body image, travel, odors, leakage and appliance support matter even when diversion improves overall quality of life. Reassess the patient's goals and symptoms rather than treating anatomical closure as the sole measure of success.[21]

References​

1. Gaertner WB, Burgess PL, Davids JS, et al. "The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula." Dis Colon Rectum. 2022;65(8):964–985. doi:10.1097/DCR.0000000000002473

2. ACOG Committee on Practice Bulletins—Gynecology. "ACOG practice bulletin no. 210: fecal incontinence." Obstet Gynecol. 2019;133(4):e260–e273. doi:10.1097/AOG.0000000000003187

3. Shackley DC, Brew CJ, Bryden AA, et al. "The staged management of complex entero-urinary fistulae." BJU Int. 2000;86(6):624–629. doi:10.1046/j.1464-410x.2000.00871.x

4. Obi M, Kanters A, Spivak AR, et al. "Determinants of fecal diversion prior to rectovaginal fistula surgery." J Gastrointest Surg. 2026:102442. doi:10.1016/j.gassur.2026.102442

5. Fu J, Liang Z, Zhu Y, Cui L, Chen W. "Surgical repair of rectovaginal fistulas: predictors of fistula closure." Int Urogynecol J. 2019;30(10):1659–1665. doi:10.1007/s00192-019-04082-w

6. Liu Z, Ren L, Zhang J, Guo D. "Surgical outcomes in laparoscopic vs open diverting colostomy for radiation-related rectovaginal fistula." Med Sci Monit. 2025;31:e947487. doi:10.12659/MSM.947487

7. Corte H, Maggiori L, Treton X, et al. "Rectovaginal fistula: what is the optimal strategy? An analysis of 79 patients undergoing 286 procedures." Ann Surg. 2015;262(5):855–860. doi:10.1097/SLA.0000000000001461

8. Beddy D, Poskus T, Umbreit E, et al. "Impact of radiotherapy on surgical repair and outcome in patients with rectourethral fistula." Colorectal Dis. 2013;15(12):1515–1520. doi:10.1111/codi.12350

9. Vanni AJ, Buckley JC, Zinman LN. "Management of surgical and radiation-induced rectourethral fistulas with an interposition muscle flap and selective buccal mucosal onlay graft." J Urol. 2010;184(6):2400–2404. doi:10.1016/j.juro.2010.08.004

10. Hanna JM, Turley R, Castleberry A, et al. "Surgical management of complex rectourethral fistulas in irradiated and nonirradiated patients." Dis Colon Rectum. 2014;57(9):1105–1112. doi:10.1097/DCR.0000000000000175

11. Linder BJ, Umbreit EC, Larson D, et al. "Effect of prior radiotherapy and ablative therapy on surgical outcomes for the treatment of rectourethral fistulas." J Urol. 2013;190(4):1287–1291. doi:10.1016/j.juro.2013.03.077

12. Martins FE, Felicio J, Oliveira TR, et al. "Adverse features of rectourethral fistula requiring extirpative surgery and permanent dual diversion: our experience and recommendations." J Clin Med. 2021;10(17):4014. doi:10.3390/jcm10174014

13. Lo Re M, Pezzoli M, Garcia Rojo E, et al. "A systematic review on the surgical management of acquired rectourethral fistula." Int J Impot Res. 2026;38(3):214–225. doi:10.1038/s41443-025-01100-y

14. Ortega Ferrete A, López E, Juez Sáez LD, et al. "Fournier's gangrene and fecal diversion. When, in which patients, and what type should I perform?" Langenbecks Arch Surg. 2023;408(1):428. doi:10.1007/s00423-023-03137-3

15. Furr J, Watts T, Street R, et al. "Contemporary trends in the inpatient management of Fournier's gangrene: predictors of length of stay and mortality based on population-based sample." Urology. 2017;102:79–84. doi:10.1016/j.urology.2016.09.021

16. Tarasconi A, Perrone G, Davies J, et al. "Anorectal emergencies: WSES-AAST guidelines." World J Emerg Surg. 2021;16(1):48. doi:10.1186/s13017-021-00384-x

17. Sarofim M, Di Re A, Descallar J, Toh JWT. "Relationship between diversional stoma and mortality rate in Fournier's gangrene: a systematic review and meta-analysis." Langenbecks Arch Surg. 2021;406(8):2581–2590. doi:10.1007/s00423-021-02175-z

18. Huang S, Chen DC, Perera M, Lawrentschuk N. "Role of diverting colostomy and reconstruction in managing Fournier's gangrene — a narrative review." BJU Int. 2024;134(4):534–540. doi:10.1111/bju.16365

19. Kudsk KA, Hanna MK. "Management of complex perineal injuries." World J Surg. 2003;27(8):895–900. doi:10.1007/s00268-003-6719-z

20. Yu YS, Weng YT, Wu CW, Tzeng YS. "Successful perianal wound treatment using the fecal management system: a report of 2 cases." Ann Plast Surg. 2025;94(3S Suppl 1):S87–S89. doi:10.1097/SAP.0000000000004197

21. Bordeianou LG, Thorsen AJ, Keller DS, et al. "The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of fecal incontinence." Dis Colon Rectum. 2023;66(5):647–661. doi:10.1097/DCR.0000000000002776

22. Bharucha AE, Rao SSC, Shin AS. "Surgical interventions and the use of device-aided therapy for the treatment of fecal incontinence and defecatory disorders." Clin Gastroenterol Hepatol. 2017;15(12):1844–1854. doi:10.1016/j.cgh.2017.08.023

23. Arndt KR, Papadimatos S, Allar BG, et al. "Complications and readmissions in diverting loop ileostomies and loop colostomies." Dis Colon Rectum. 2026;69(5):826–835. doi:10.1097/DCR.0000000000004156

24. Davis BR, Valente MA, Goldberg JE, et al. "The American Society of Colon and Rectal Surgeons clinical practice guidelines for ostomy surgery." Dis Colon Rectum. 2022;65(10):1173–1190. doi:10.1097/DCR.0000000000002498

25. Becker MAJ, Pronk AJM, Gecse K, et al. "Long-term outcomes of 'temporary' defunctioning in patients with severe perianal Crohn's disease." Colorectal Dis. 2025;27(2):e17289. doi:10.1111/codi.17289

26. Rosen DR, Brown ME, Cologne KG, Ault GT, Strumwasser AM. "Long-term follow-up of Fournier's gangrene in a tertiary care center." J Surg Res. 2016;206(1):175–181. doi:10.1016/j.jss.2016.06.091

27. Hajibandeh S, Hajibandeh S, Maw A. "Purse-string skin closure versus linear skin closure in people undergoing stoma reversal." Cochrane Database Syst Rev. 2024;3:CD014763. doi:10.1002/14651858.CD014763.pub2

28. ConvaTec. Flexi-Seal PROTECT PLUS Fecal Management System: Directions for Use. AP-030359-AM-EM. Manufacturer instructions.

29. Eastern Association for the Surgery of Trauma. Management of penetrating extraperitoneal rectal injuries. 2016 practice management guideline; update listed as in progress. Official guideline.