Rectovaginal fistulas after radiation therapy: treatment options and outcomes - a narrative review

Radiation-induced rectovaginal fistula (RI-RVF) is a severe late complication of pelvic radiotherapy, arising predominantly after treatment for gynaecological malignancy and characterised by fibrosis, ischaemia, impaired healing and poor quality of life. No universally accepted treatment standard exists.

A structured narrative review searched PubMed and Google Scholar (January 2020-July 2026), with earlier landmark studies identified through reference-list screening; it was not conducted or reported as a systematic review. Eight reviewers screened records singly rather than in duplicate, with uncertain cases resolved by consensus with two senior supervisors. Predefined outcome domains beyond anatomical closure were extracted, including stoma-free survival, continence, low anterior resection syndrome, sexual function, pelvic pain and patient-reported quality of life. Seventy publications were cited, of which 26 constitute the clinical evidence base; the remaining 44 provided anatomical, radiotherapeutic, methodological or background context.

Faecal diversion is an appropriate initial, bridging or palliative intervention rather than a universal first-line treatment; spontaneous closure after diversion alone is uncommon (6/50; 12%), and colostomy and ileostomy carry distinct complication profiles. The Martius flap is applied mainly to low fistulas with small defects; the quoted 1.5 cm threshold reflects selection criteria in published series rather than a validated cut-off, and larger defects have been repaired successfully. Gracilis interposition is used for complex or recurrent fistulas, although supporting meta-analytic data derive from heterogeneous perineal fistula cohorts in which only approximately 18% of patients had received radiotherapy. Delayed coloanal anastomosis was associated with fewer anastomotic complications than immediate anastomosis in low rectal cancer meta-analyses, though not consistently across endpoints; this evidence does not derive from RI-RVF populations. Functional and patient-reported outcomes were reported inconsistently, with non-comparable instruments. Evidence for stromal vascular fraction is confined to case reports and small series.

The overall certainty of the available evidence is low. Martius flap reconstruction, graciloplasty and delayed coloanal anastomosis are established options, but reported efficacy must be interpreted against the heterogeneity and indirectness of the available evidence. Stromal vascular fraction remains experimental. Prospective studies should redefine success beyond anatomical closure to include stoma-free survival, functional recovery and patient-reported quality of life.