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Endorectal Advancement Flap (ERAF) for Rectovaginal Fistula

Endorectal advancement flap, with or without sphincteroplasty, is recommended by ASCRS for many rectovaginal fistulas (RVFs), although the recommendation rests on low-quality evidence. The operation covers the rectal opening with mobilized, vascularized rectal tissue. Anatomy, anal continence, sphincter integrity, inflammation and previous repairs determine whether a flap alone is appropriate.[1]

See Rectovaginal Fistula and the Female Fistula treatment atlas.

Selection and Preparation​

A local flap is an option for accessible low or mid-level RVFs with adequate tissue. Assess fistula height, openings, scar, continence and the sphincter complex; use endoanal ultrasound or pelvic MRI when needed to define defects or complex tracts. A sphincter defect matters particularly when accompanied by fecal incontinence. Active malignancy, poor irradiated tissue, uncontrolled infection or active rectal inflammation may require a different strategy.[1][4]

  • Drain sepsis before elective closure. A draining seton can help a narrow or branching RVF with associated inflammation or abscess; it is not a mandatory fixed-duration step for every fistula.[1]
  • Coordinate Crohn's treatment. ECCO 2024 supports medical treatment and selected surgical closure of anogenital/rectogenital fistulas through an experienced multidisciplinary team. Its advancement-flap recommendation for complex perianal Crohn's fistulas selects patients without proctitis or anal stenosis; those broader perianal healing estimates should not be relabeled as RVF-specific outcomes.[3]
  • Individualize diversion. A stoma may aid symptom control or complex reconstruction, but available RVF flap studies have not established a routine healing benefit for all patients.[1]

In Sonoda's mixed anorectal/RVF cohort, prior abscess drainage and seton placement were associated with healing. These observational findings support attention to infection control, not a causal guarantee from either intervention or a prescribed number of weeks before surgery.[5]

Operative Framework​

Positioning and exposure should provide atraumatic access to the rectal opening. The core steps are tract preparation, closure of the internal opening and advancement of a well-perfused rectal flap over it.[1][4]

  1. Identify the tract and prepare the opening. Curette the fistula tract as appropriate, protecting the remaining sphincter and rectovaginal tissue. Dye passage can help localization but does not establish complete debridement.
  2. Close the internal opening. Use an absorbable repair suited to the tissue and planned flap. Suture size and pattern are technique choices rather than a universally validated prescription.
  3. Mobilize a broad-based flap. Preserve its vascular supply and obtain enough mobility for coverage without tension. Some techniques include internal-sphincter or rectal-muscle fibers; neither maximal thickness nor a fixed flap length is established as optimal for all RVFs.
  4. Advance and secure the flap. Cover the repaired opening, avoid tension and separate the closure lines where feasible. Management of the vaginal opening depends on drainage needs and the chosen reconstruction.
  5. Address very low anatomy separately. A rectal mucosal flap brought too distally can cause ectropion. An anoderm/perianal skin flap or another repair can be considered instead of automatically applying the same rectal flap.[1]

Muscular-plication variant: de Parades described internal-opening closure, anorectal muscular plication and mucosal advancement in 23 selected women. Patients with external-sphincter defects, active Crohn's proctitis, anorectal stricture, malignancy or radiation-related fistulas were excluded. Healing was 15/23 (65%) at mean 14 months; mean Wexner scores were 1.3 before and 0.6 afterward. This uncontrolled series does not establish superior healing or protection from incontinence compared with other techniques.[6]

When the Sphincter Also Requires Repair​

A symptomatic anterior sphincter defect changes the reconstructive goal: fistula closure and anal continence should both be addressed. Options include a flap combined with tailored sphincter reconstruction or episioproctotomy. Sphincteroplasty is not the only possible durable treatment for fecal incontinence, and anatomy alone does not ensure functional recovery.[1]

The frequently cited 41% versus 80% healing comparison comes from 52 patients undergoing 62 procedures: 11/27 advancement-flap procedures and 28/35 sphincteroplasty procedures with or without levatorplasty. It is not a randomized comparison of adding sphincteroplasty to an otherwise identical flap, nor a guaranteed benefit above 80%.[1]

Khanduja's 20-patient obstetric series combined mucosal advancement with different sphincter reconstructions, including two-layer repair, one-layer overlap and one isolated internal-sphincter repair. Vaginal stool/flatus discharge resolved in all 20; 14/20 regained perfect anal continence, while six retained liquid-stool or flatus incontinence. Nineteen rated the result excellent or good, and no complications were reported in this small series.[2]

Li's 2025 cohort associated diameter greater than 1 cm with flap failure. Only two failures were subsequently treated successfully by sphincter repair. This does not establish a universal 1-cm threshold for choosing sphincteroplasty or mandate a six-month interval.[7]

Evidence and Counseling​

StudyPopulation and denominatorWhat the results support
Jones 198739 mixed anorectal fistulas, including 23 RVFsOverall healing was 27/39 (69.2%). Within the RVF subgroup, healing was 60% with Crohn's disease versus 76.9% with other causes; these are small observational subgroups.[4]
Sonoda 2002105 enrolled; 99 followed, including 37 RVFs and 62 anorectal fistulas63.6% primary healing applies to the whole mixed cohort. Crohn's disease and RVF location were associated with failure; this is not a 63.6% RVF-specific success rate.[5]
de Parades 201123 selected RVFs without external-sphincter defects15/23 healed after the muscular-plication variant; no controlled comparison establishes its advantage.[6]
Li 202557 simple low/mid RVFs; 19 congenital and 19 obstetricFirst-repair success 66.7%; overall 70.2% after repetition of the technique. Larger diameter was associated with failure.[7]

Corte's 72% overall healing represents 57/79 patients treated with 286 procedures of many types, only 46 of which were rectal advancement flaps. Associations with major surgery, diversion or earlier intervention are vulnerable to selection and repeated-procedure effects; the study does not supply an ERAF-specific success rate or justify routine early diversion.[8]

Counsel about recurrent fistula, infection/abscess, flap breakdown, ectropion and altered continence. Closure of vaginal leakage is distinct from anal continence and sexual function. Crohn's activity, prior irradiation, failed repairs and sphincter dysfunction can reduce the likelihood of healing. Sonoda's high-dose prednisone finding was a trend in a retrospective cohort, not a validated dose cutoff or an instruction to abruptly stop steroids.[1][3][5]

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. Khanduja KS, Padmanabhan A, Kerner BA, Wise WE, Aguilar PS. "Reconstruction of rectovaginal fistula with sphincter disruption by combining rectal mucosal advancement flap and anal sphincteroplasty." Dis Colon Rectum. 1999;42(11):1432–1437. doi:10.1007/BF02235043

3. Adamina M, Minozzi S, Warusavitarne J, et al. "ECCO Guidelines on Therapeutics in Crohn’s Disease: Surgical Treatment." J Crohns Colitis. 2024;18(10):1556–1582. doi:10.1093/ecco-jcc/jjae089

4. Jones IT, Fazio VW, Jagelman DG. "The use of transanal rectal advancement flaps in the management of fistulas involving the anorectum." Dis Colon Rectum. 1987;30(12):919–923. doi:10.1007/BF02554276

5. Sonoda T, Hull T, Piedmonte MR, Fazio VW. "Outcomes of primary repair of anorectal and rectovaginal fistulas using the endorectal advancement flap." Dis Colon Rectum. 2002;45(12):1622–1628. doi:10.1007/s10350-004-7249-y

6. de Parades V, Dahmani Z, Blanchard P, et al. "Endorectal advancement flap with muscular plication: a modified technique for rectovaginal fistula repair." Colorectal Dis. 2011;13(8):921–925. doi:10.1111/j.1463-1318.2010.02338.x

7. Li X, Shao W, Sun G. "A single-center retrospective analysis of endorectal advancement flaps used for the treatment of simple rectovaginal fistulas." Scand J Gastroenterol. 2025;60(4):307–311. doi:10.1080/00365521.2025.2468493

8. 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; discussion 860–861. doi:10.1097/SLA.0000000000001461