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Transanal Minimally Invasive Repair (MITAR / TAMIS / R-TAMIS / TEM-TEO) for RVF and RUF

Transanal platforms can provide magnified access for selected rectovaginal fistula (RVF) and rectourethral fistula (RUF) repairs. Local repair may avoid a perineal incision and deliberate anal-sphincter division, but it still involves internal dissection and suturing; some patients also need fecal diversion. It should not be described as universally incisionless or free of sphincter morbidity. Evidence consists mainly of small retrospective series and technical reports with substantially different patient selection.[1][2][3][6]

Companion procedures include Transperineal RUF Repair, Endorectal Advancement Flap for RVF, York–Mason Repair and Transabdominal RVF Repair.

Platform Distinctions​

PlatformAccess and instrumentsInterpretation
MITARParks' anal retractor with laparoscopic instrumentsNicita's local RUF repair; does not require an insufflated transanal port.[1]
TAMISTransanal access port with laparoscopic instruments and insufflationCan support dissection or advancement-flap construction; the platform is not itself a fistula-repair method.[4]
R-TAMISTransanal port with robotic instrumentsOffers articulated instrumentation and magnified visualization; better clinical outcomes than other routes are unproven.[2][5]
TEM / TEORigid transanal rectoscope with endoscopic optics and instrumentsReported for both RVF and RUF, with variable results.[3][6][8]

Determine fistula location, tissue quality, associated urinary/anal-sphincter disease, prior repairs and need for interposition before choosing a platform. Active infection and inadequate tissue planes need to be addressed; an endoscopic view does not make an unsuitable closure suitable. Be prepared to use another approach if safe mobilization cannot be achieved.[8][11][12]

MITAR for Selected RUF​

Nicita's retrospective series included 12 patients and excluded fistulas larger than 1.5 cm, sepsis and fecaluria. The authors had no experience with radiation-induced fistulas in this series. These are the study's selection boundaries, not universal limits for every transanal technique.[1]

The reported sequence was:

  1. Identify the tract by cystoscopy and place a 5F guide catheter through it under vision.
  2. Expose the rectal opening with a Parks' retractor and laparoscopic instruments.
  3. Make a lozenge-shaped rectal-wall incision parallel to the rectal axis and dissect the fibrotic margins to expose healthy tissue and the urinary opening.
  4. Close the urinary side with interrupted sutures and perform a bladder leak test.
  5. Close the rectal wall separately with interrupted sutures. This technique avoided electrocoagulation to limit thermal injury.[1]

All 12 fistulas were closed without recurrence at median 21 months (range 12–74); one early complication occurred. Median operating time was 58 minutes and hospital stay 1.5 days. The authors reported no need for colostomy in this selected cohort. This does not establish that fecal diversion can be omitted in patients with different anatomy or tissue injury.[1]

Robotic Transanal Repair​

RUF: Hebert 2021​

The two-patient report used prone jackknife positioning, a GelPOINT Path secured with a Lone Star system, robotic trocars and AirSeal insufflation. After separating rectum and urethra and excising the tract, the two defects were closed independently with absorbable sutures.[2]

Both patients were discharged by postoperative day two and had no recurrence or major morbidity at at least 15 months. Both had a diverting loop ileostomy: repair integrity was assessed endoscopically at three months around reversal. Four-week Foley drainage was part of that series' protocol. Two favorable cases establish feasibility rather than comparative safety or a mandatory postoperative schedule.[2]

RVF: Mohammed Salih 2025​

This case report describes separate vaginal and rectal closure, with fibrin sealant and acellular dermal mesh added to the vaginal repair. The patient went home the next day without major immediate complications. The accessible abstract does not establish long-term closure, and the adjuncts are not validated requirements for robotic RVF repair.[5]

TEM / TEO for RVF​

ReportPopulation and resultWhat limits interpretation
D'Ambrosio 201213 patients, median 25 months; one recurrence that recurred again after repeat TEMTwo septal hematoma/abscess complications and two cases of moderate sphincter hypotonia were reported. Avoid a zero-morbidity claim.[3]
Yuan 202017 mid-low RVFs: 12 treated through an anal route and five vaginally; three recurrences in the anal group and none in the vaginal groupMedian follow-up eight months. Some repairs used direct vision after initial endoscopic exploration; nine patients had diverting ileostomy. This was not a randomized route comparison.[7]
Lapergola 2026One approximately 2-cm high post-anastomotic RVF, 16–18 cm from the anal verge, closed with a TEO approach and no recurrence at two yearsNonirradiated patient with a hostile abdomen and an existing protective ileostomy; an IDEAL stage 1 technical report, not evidence of comparative effectiveness.[8]

High Post-anastomotic RVF: Technical Lessons​

The complete 2026 report describes endoscopic marking, circumferential separation of the rectal/colonic and vaginal walls, confirmation of adequate reciprocal mobilization, then longitudinal vaginal and transverse colorectal closure. The authors emphasized tension-free closure, continued identification of the rectovaginal plane and avoidance of blind traction or excessive energy. High defects can lie near the peritoneal cavity and adherent small bowel; inability to maintain a safe plane should prompt a change of approach.[8]

Closure was confirmed at three months; the ileostomy was reversed three months later. The case shows that a high defect does not always mandate abdominal access, while providing no estimate of reproducibility or risk in a broader population. The report's proposed ideal candidates had a single defined defect, no active pelvic sepsis and no previous pelvic radiotherapy.[8]

Rottoli's TAMIS-assisted advancement-flap description offers a way to extend proximal flap mobilization under endoscopic vision for high perianal or rectovaginal fistulas. Its technical abstract does not establish a clinical success rate for RUF and should not be used as such.[4]

Conflicting RUF Results and Mesh​

Serra-Aracil's study began with ten RUF patients. Two closed during conservative/diversion management, and eight proceeded to TEO/TEM repair. Only 2 of 8 transanal repairs healed; six failures underwent transperineal gracilis salvage.[6]

All four patients receiving biological mesh recurred, compared with two of four without mesh. This is a concerning uncontrolled observation, but it does not prove that mesh caused the failures. The groups were small and not randomized. The appropriate conclusion is that this series did not support routine TEO/TEM or biological mesh for its RUF population; it cannot establish a universal causal rule about every biomaterial or every transanal operation.[6]

Procedures That Should Be Kept Separate​

  • Robotic/laparoscopic transabdominal RUF repair: Medina reported 15 selected patients, nine robotic and six laparoscopic. All met the study's closure criteria at 12 months, but nine postoperative complications were reported. This is evidence about abdominal minimally invasive reconstruction, not TAMIS.[9]
  • TAMIS-assisted proctectomy with Turnbull–Cutait reconstruction: Martín-Pérez reported three radiation-associated RUFs with successful closure and subsequent ileostomy reversal. This combines major rectal resection and delayed coloanal reconstruction; it is a salvage operation, not a local fistula closure through a port. See Turnbull–Cutait for RUF.[10]

Guideline Context and Counseling​

ASCRS 2022 recommends endorectal advancement flap with or without sphincteroplasty for most RVFs, and vascularized gracilis or Martius interposition for recurrent or complex RVFs; both recommendations rely on low-quality evidence. Post-anastomotic and radiation-related disease may require more extensive reconstruction. The guideline's weak recommendation about endoscopic/laser methods specifically concerns fistula-in-ano and should not be presented as an endorsement of TAMIS for RUF or RVF.[11]

The 2013 RUF systematic review found transanal operations in 5.9% of its 416 patients, with transperineal repairs more common. Those are historical study proportions, not a current usage survey or randomized comparison.[12]

Explain the potential for avoiding an external perineal incision while also discussing recurrent fistula, abscess, sphincter symptoms, the possibility of another route or flap, and temporary or permanent diversion. Published hospital stays and closure percentages should be tied to their individual cohorts; comparing them across unrelated small series cannot establish that one platform offers faster recovery or better function.[1][2][3][6][8]

Videos​

Robotic TAMIS rectourethral fistula repair
Operative video paralleling the Hebert 2021 R-TAMIS technique (GelPOINT Path + da Vinci, prone jackknife)

References​

1. Nicita G, Villari D, Caroassai Grisanti S, et al. "Minimally invasive transanal repair of rectourethral fistulas." Eur Urol. 2017;71(1):133–138. doi:10.1016/j.eururo.2016.06.006

2. Hebert KJ, Naik N, Allawi A, et al. "Rectourethral fistula repair using robotic transanal minimally invasive surgery (TAMIS) approach." Urology. 2021;154:338. doi:10.1016/j.urology.2021.05.027

3. D'Ambrosio G, Paganini AM, Guerrieri M, et al. "Minimally invasive treatment of rectovaginal fistula." Surg Endosc. 2012;26(2):546–550. doi:10.1007/s00464-011-1917-5

4. Rottoli M, Di Simone MP, Poggioli G. "TAMIS-flap technique: full-thickness advancement rectal flap for high perianal fistulae performed through transanal minimally invasive surgery." Surg Laparosc Endosc Percutan Tech. 2019;29(4):e53–e56. doi:10.1097/SLE.0000000000000692

5. Mohammed Salih S, Zajicek J, Allawi A. "Same-day repair of recto-vaginal fistula using the robotic trans-anal minimally invasive technique — how we do it." J Laparoendosc Adv Surg Tech A. 2025. doi:10.1177/10926429251399211

6. Serra-Aracil X, Labró-Ciurans M, Mora-López L, et al. "The place of transanal endoscopic surgery in the treatment of rectourethral fistula." Urology. 2018;111:139–144. doi:10.1016/j.urology.2017.08.049

7. Yuan X, Chen H, Chen C, et al. "Minimally invasive treatment of mid-low rectovaginal fistula: a transanal endoscopic surgery study." Surg Endosc. 2020;34(9):3971–3977. doi:10.1007/s00464-019-07174-2

8. Lapergola A, Alicata F, Hag P, et al. "A fully transanal endoscopic approach for large post-anastomotic high rectovaginal fistulas: an IDEAL stage 1 technical note." Colorectal Dis. 2026;28(3):e70419. doi:10.1111/codi.70419

9. Medina LG, Sayegh AS, La Riva A, et al. "Minimally invasive management of rectourethral fistulae." Urology. 2022;169:102–109. doi:10.1016/j.urology.2022.05.060

10. Martín-Pérez B, Dar R, Bislenghi G, et al. "Transanal minimally invasive proctectomy with two-stage Turnbull-Cutait pull-through coloanal anastomosis for iatrogenic rectourethral fistulas." Dis Colon Rectum. 2021;64(2):e26–e29. doi:10.1097/DCR.0000000000001850

11. 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

12. Hechenbleikner EM, Buckley JC, Wick EC. "Acquired rectourethral fistulas in adults: a systematic review of surgical repair techniques and outcomes." Dis Colon Rectum. 2013;56(3):374–383. doi:10.1097/DCR.0b013e318274dc87