VM11 - Rectal Neovagina with Turnbull-Cutait: A Solution for Large Rectovaginal Fistulas After Radiotherapy

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Purpose/Background: The management of rectovaginal fistulas is complex and often requires either perineal or abdominal surgical approaches. While smaller fistulas in non-irradiated tissues can be effectively treated with techniques such as rectal advancement flaps and tissue interposition (e.g., omentoplasty, bulbocavernosus, or gracilis muscle flaps), the treatment of large fistulas, particularly those occurring after radiotherapy, presents significant challenges. Dr. Oscar Simonsen (in memoriam) pioneered the Rectal Neovagina technique at the University of São Paulo, Brazil, to address large post-radiotherapy fistulas, most commonly seen in patients with bulky cervical cancer, which is highly sensitive to chemoradiotherapy. This innovative approach involves creating a neovagina using the rectum.

Methods/Interventions: The procedure begins with high ligation of the inferior mesenteric vein and artery, followed by full mobilization of the splenic flexure. Posterior dissection of the rectum is performed down to the pelvic floor, followed by a transanal mucosectomy up to the level of the fistula, which is sutured closed to create a new rectovaginal chamber. A 180-degree posterior rectotomy is then performed just above the anorectal ring, and the left colon is brought down to the anal canal, posterior to the rectum. The colon can either be anastomosed primarily using a hand-sewn coloanal technique or exteriorized in a Turnbull-Cutait fashion for delayed anastomosis. Delayed anastomosis is particularly advantageous in complicated cases, as it may increase the likelihood of a successful outcome.

Results/Outcomes: In this report, we present the case of a 46-year-old woman with a body mass index of 44 who developed a very large rectovaginal fistula following chemoradiotherapy for bulky cervical cancer. The patient initially underwent loop sigmoid colostomy prior to treatment. Despite achieving a complete response, she developed a persistent and extensive rectovaginal fistula after 18 months of follow-up, along with significant fibrosis involving the rectum, parametrium, and ureter, with no evidence of tumor recurrence. During her office visit, she expressed her desire to reverse the colostomy, prompting the consideration of Simonsen’s procedure. The patient tolerated the procedure well and experienced an uneventful recovery.

Conclusion/Discussion: This video illustrates all the steps of this uncommon yet highly effective technique for addressing complex rectovaginal fistulas.