title: The disappointing quality of published studies on operative techniques for rectovaginal fistulas: a blueprint for a prospective multi-institutional study.
abstract: BACKGROUND
  Treatment of rectovaginal fistulas is difficult, and many surgical interventions have been developed. The best surgical intervention for the closure of these fistulas is still unclear.
  
  
  OBJECTIVE
  A systematic review was performed reporting the outcomes of different surgical techniques for rectovaginal fistulas.
  
  
  METHODS
  Medline (PubMed, Ovid), Embase (Ovid), and The Cochrane Library databases were searched for eligible articles as well as the references of these articles.
  
  
  METHODS
  Two independent reviewers analyzed the search results for eligible articles based on title, abstract, and described results.
  
  
  METHODS
  Any surgical intervention for the closure of rectovaginal fistulas was included.
  
  
  METHODS
  The main outcome was closure rate. Secondary outcomes were quality of life, morbidity, and the effect on sexual functioning.
  
  
  RESULTS
  Many articles with different operative techniques were identified and classified in the following categories: advancement flaps (endorectal and endovaginal), transperineal closure, Martius procedure, gracilis muscle transposition, rectal resections, transabdominal closure, mesh repair, plugs, endoscopic repairs, closure with biomaterials, and miscellaneous techniques. Results vary widely with closure rates between 0% and >80%. None of the studies were randomized. Because of the poor quality of the identified studies, the comparison of results and performance of a meta-analysis were not possible.Data regarding the secondary outcomes were mostly unavailable.
  
  
  CONCLUSIONS
  The major limitation of this review was the limited availability of high-quality prospective studies, making it impossible to perform a meta-analysis.
  
  
  CONCLUSIONS
  No conclusion about the best surgical intervention for rectovaginal fistulas could be formulated. More large studies of high quality are needed to find the best treatment for rectovaginal fistulas. A design for these high-quality studies was formulated.
authors.affiliation: Department of Surgery and Colorectal Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.
authors.forename: Kevin W
authors.initials: KW
authors.lastname: Göttgens
authors.forename: Reinier R
authors.initials: RR
authors.lastname: Smeets
authors.forename: Laurents P
authors.initials: LP
authors.lastname: Stassen
authors.forename: Geerard
authors.initials: G
authors.lastname: Beets
authors.forename: Stephanie O
authors.initials: SO
authors.lastname: Breukink
mesh_terms: D001672:Biocompatible Materials; D005260:Female; D013509:Gynecologic Surgical Procedures / Q000379:methods*; D006801:Humans; D010502:Perineum / Q000601:surgery; D012006:Rectovaginal Fistula / Q000601:surgery*; D012007:Rectum / Q000601:surgery; D013524:Surgical Flaps; D013526:Surgical Mesh; D016896:Treatment Outcome
chemical_list: D001672:Biocompatible Materials