Review
Anorectal benign disease
- Recent advances in the diagnosis and treatment of complex anal fistula
-
Pankaj Garg, Kaushik Bhattacharya, Vipul D. Yagnik, G. Mahak
-
Ann Coloproctol. 2024;40(4):321-335. Published online August 30, 2024
-
DOI: https://doi.org/10.3393/ac.2024.00325.0046
-
-
6,615
View
-
566
Download
-
1
Web of Science
-
3
Citations
-
Abstract
PDF
- Anal fistula can be a challenging condition to manage, with complex fistulas presenting even greater difficulties. The primary concerns in treating this condition are a risk of damage to the anal sphincters, which can compromise fecal continence, and refractoriness to treatment, as evidenced by a high recurrence rate. Furthermore, the treatment of complex anal fistula involves several additional challenges. Satisfactory solutions to many of these obstacles remain elusive, and no consensus has been established regarding the available treatment options. In summary, complex anal fistula has no established gold-standard treatment, and the quest for effective therapies continues. This review discusses and highlights groundbreaking advances in the management of complex anal fistula over the past decade.
-
Citations
Citations to this article as recorded by

- Understanding the anatomical basis of anorectal fistulas and their surgical management: exploring different types for enhanced precision and safety
Asim M. Almughamsi, Yasir Hassan Elhassan
Surgery Today.2025;[Epub] CrossRef - From the Editor: Uniting expertise, a new era of global collaboration in coloproctology
In Ja Park
Annals of Coloproctology.2024; 40(4): 285. CrossRef - Surgeon oriented reporting template for magnetic resonance imaging and endoanal ultrasound of anal fistulas enhances surgical decision-making
Si-Ze Wu
World Journal of Radiology.2024; 16(12): 712. CrossRef
Original Article
Anorectal benign disease
- Immediate sphincter repair following fistulotomy for anal fistula: does it impact the healing rate and septic complications?
-
Maher A. Abbas, Anna T. Tsay, Mohammad Abbass
-
Ann Coloproctol. 2024;40(3):217-224. Published online June 28, 2024
-
DOI: https://doi.org/10.3393/ac.2022.01144.0163
-
-
2,158
View
-
219
Download
-
1
Web of Science
-
1
Citations
-
Abstract
PDF
- Purpose
Fistulotomy is considered the most effective treatment for anal fistula; however, it carries a risk of incontinence. Sphincteroplasty in the setting of fistulotomy is not standard practice due to concerns regarding healing and potential infectious complications. We aimed to compare the outcomes of patients who underwent fistulotomy with primary sphincteroplasty to those who did not undergo repair.
Methods
This was a retrospective review of consecutive patients who underwent fistulotomy for cryptoglandular anal fistula. All operations were performed by one colorectal surgeon. Sphincteroplasty was performed for patients perceived to be at higher risk for continence disturbance. The main outcome measures were the healing rate and postoperative septic complications.
Results
In total, 152 patients were analyzed. Group A (fistulotomy with sphincteroplasty) consisted of 45 patients and group B (fistulotomy alone) included 107 patients. Both groups were similar in age (P=0.16) and sex (P=0.20). Group A had higher proportions of multiple fistulas (26.7% vs. 6.5%, P<0.01) and complex fistulas (mid to high transsphincteric, 37.8% vs. 10.3%; P<0.01) than group B. The median follow-up time was 8 weeks. The overall healing rate was similar in both groups (93.3% vs. 90.6%, P=0.76). No significant difference between the 2 groups was noted in septic complications (6.7% vs. 3.7%, P=0.42).
Conclusion
Fistulotomy with primary sphincter repair demonstrated a comparable healing rate to fistulotomy alone, without an increased risk of postoperative septic complications. Further prospective randomized studies are needed to confirm these findings and to explore the functional outcomes of patients who undergo sphincteroplasty.
-
Citations
Citations to this article as recorded by

- Achieving a high cure rate in complex anal fistulas: understanding the conceptual role of the Garg cardinal principles
Pankaj Garg, Nicola Clemente, James C. W. Khaw
Annals of Coloproctology.2024; 40(5): 521. CrossRef
Technical Note
- Transanal opening of the intersphincteric space (TROPIS): a novel procedure on the horizon to effectively manage high complex anal fistulas
-
Pankaj Garg, Anvesha Mongia
-
Ann Coloproctol. 2024;40(1):74-81. Published online October 24, 2023
-
DOI: https://doi.org/10.3393/ac.2022.01263.0180
-
-
3,104
View
-
254
Download
-
5
Web of Science
-
5
Citations
-
Abstract
PDF
- Anal fistulas, especially complex and high fistulas, are difficult to manage. The transanal opening of the intersphincteric space (TROPIS) procedure was first described in 2017, and a high success rate of over 90% was reported in high complex fistulas. Since then, more studies and even a meta-analysis have corroborated the high efficacy of this procedure in high fistulas. Conventionally, the main focus was to close the internal (primary) opening for the fistula to heal. However, most complex fistulas have a component of the fistula tract in the intersphincteric plane. This component is like an abscess (sepsis) in a closed space (2 muscle layers). It is a well-known fact that in the presence of sepsis, healing by secondary intention leads to better results than attempting to heal by primary intention. Therefore, TROPIS is the first procedure in which, instead of closing the internal opening, the opening is widened by laying open the fistula tract in the intersphincteric plane so that healing can occur by secondary intention. Although the drainage of high intersphincteric abscesses through the transanal route was described 5 decades ago, the routine utilization of TROPIS for the definitive management of high complex fistulas was first described in 2017. The external anal sphincter (EAS) is completely spared in TROPIS, as the fistula tract on either side of the EAS is managed separately—inner (medial) to the EAS by laying open the intersphincteric space and outer (lateral) to the EAS by curettage or excision.
-
Citations
Citations to this article as recorded by

- Recent advances in the diagnosis and treatment of complex anal fistula
Pankaj Garg, Kaushik Bhattacharya, Vipul D. Yagnik, G. Mahak
Annals of Coloproctology.2024; 40(4): 321. CrossRef - Tissue engineering and regenerative medicine approaches in colorectal surgery
Bigyan B. Mainali, James J. Yoo, Mitchell R. Ladd
Annals of Coloproctology.2024; 40(4): 336. CrossRef - Achieving a high cure rate in complex anal fistulas: understanding the conceptual role of the Garg cardinal principles
Pankaj Garg, Nicola Clemente, James C. W. Khaw
Annals of Coloproctology.2024; 40(5): 521. CrossRef - Comparative Evaluation Between Cutting of the Intersphincteric Space vs Cutting Seton in High Anal Fistula: A Randomized Controlled Trial
Jiawei Qin, Yanlan Wu, Xueping Zheng, Kunlan Wu, Gongjian Dai, Yanyan Tan, Xu Yang, Yuqing Sun
Journal of the American College of Surgeons.2024; 239(6): 563. CrossRef - Invited Commentary: The Quest for the Panacea Treatment for Anal Fistula
Steven D Wexner
Journal of the American College of Surgeons.2024; 239(6): 573. CrossRef
Original Articles
Anorectal benign disease
- Garg scoring system to predict long-term healing in cryptoglandular anal fistulas: a prospective validation study
-
Sushil Dawka, Vipul D. Yagnik, Baljit Kaur, Geetha R. Menon, Pankaj Garg
-
Ann Coloproctol. 2024;40(5):490-497. Published online October 11, 2022
-
DOI: https://doi.org/10.3393/ac.2022.00346.0049
-
-
2,637
View
-
107
Download
-
5
Web of Science
-
5
Citations
-
Abstract
PDF
- Purpose
Complex anal fistulas can recur after clinical healing, even after a long interval which leads to significant anxiety. Also, ascertaining the efficacy of any new treatment procedure becomes difficult and takes several years. We prospectively analyzed the validity of Garg scoring system (GSS) to predict long-term fistula healing.
Methods
In patients operated for cryptoglandular anal fistulas, magnetic resonance imaging was performed preoperatively and at 3 months postoperatively to assess fistula healing. Scores as per the GSS were calculated for each patient at 3 months postoperatively and correlated with long-term healing to check the accuracy of the scoring system.
Results
Fifty-seven patients were enrolled, but 50 were finally included (7 were excluded). These 50 patients (age, 41.2±12.4 years; 46 men) were followed up for 12 to 20 months (median, 17 months). Forty-seven patients (94.0%) had complex fistulas, 28 (56.0%) had recurrent fistulas, 48 (96.0%) had multiple tracts, 20 (40.0%) had horseshoe tracts, 15 (32.0%) had associated abscesses, 5 (10.0%) were suprasphincteric, and 8 (16.0%) were supralevator fistulas. The GSS could accurately predict long-term healing (high positive predictive value, 31 of 31 [100%]) but was not very accurate in predicting nonhealing (negative predictive value, 15 of 19 [78.9%]). The sensitivity in predicting healing was 31 of 35 (88.6%).
Conclusion
GSS accurately predicts long-term fistula with a high positive predictive value (100%) but is less accurate in predicting nonhealing. This scoring system can help allay anxiety in patients and facilitate the early validation of innovative procedures for anal fistulas.
-
Citations
Citations to this article as recorded by

- Recent Advances in the Understanding and Management of Anal Fistula from India
Vipul D. Yagnik, Sandeep Kumar, Anshul Thakur, Kaushik Bhattacharya, Sushil Dawka, Pankaj Garg
Indian Journal of Surgery.2024; 86(6): 1105. CrossRef - Rectovaginal Fistulas Not Involving the Rectovaginal Septum Should Be Treated Like Anal Fistulas: A New Concept and Proposal for a Reclassification of Rectovaginal Fistulas
Pankaj Garg, Laxmikant Ladukar, Vipul Yagnik, Kaushik Bhattacharya, Gurleen Kaur
Clinical and Experimental Gastroenterology.2024; Volume 17: 97. CrossRef - Recent advances in the diagnosis and treatment of complex anal fistula
Pankaj Garg, Kaushik Bhattacharya, Vipul D. Yagnik, G. Mahak
Annals of Coloproctology.2024; 40(4): 321. CrossRef - Predictors of outcome in cryptoglandular anal fistula according to magnetic resonance imaging: A systematic review
Alireza Teymouri, Amir Keshvari, Ali Ashjaei, Seyed Mohsen Ahmadi Tafti, Faeze Salahshour, Faezeh Khorasanizadeh, Amirhosein Naseri
Health Science Reports.2023;[Epub] CrossRef - Pankaj Garg: A Community Doctor to a Master Innovator to a Global Icon
David N. Armstrong, Iwona Sudoł-Szopińska, Vincent de Parades, Francesco Litta, Manuel Limbert, Khaw C. W. James
Global Journal of Medical, Pharmaceutical, and Biomedical Update.2023; 18: 16. CrossRef
- Incidence of anal fistula after pyogenic perianal abscess drainage in Kingdom of Bahrain
-
Zahra Abdulla Isa Yusuf Hasan, Bayan Mohamed, Rawaa AlSayegh, Raed AlMarzooq
-
Ann Coloproctol. 2023;39(1):27-31. Published online August 9, 2021
-
DOI: https://doi.org/10.3393/ac.2020.00962.0137
-
-
5,510
View
-
180
Download
-
3
Web of Science
-
4
Citations
-
Abstract
PDF
- Purpose
Perianal fistula is one of the most common anorectal diseases in adult patients, especially men. A relationship between pyogenic perianal abscess and fistula formation is established in multiple domains. This is the first exploration of such association among patients in the country as no related study has been published in Bahrain. We expect this study to be a foundation for future protocols and evidence-based practice.
Methods
A retrospective study was conducted in Salmaniya Medical Complex of Bahrain. A total of 109 patients with a diagnosis of anal abscess were included between 2015 and 2018. Data were collected from the electronic files database used in Salmaniya Medical Complex (iSeha) as well as phone calls to the patients. Collected data were analyzed using statistical software.
Results
The most predominant presentation of perianal abscess was pain. Over 50% of abscesses were classified as perianal (56.9%) and among those, left-sided abscesses were more common, followed by right-, posterior-, and anterior-sited, respectively. No recurrence of abscess was recorded among 80% of patients. A fistula developed following abscess drainage in 33.9% of patients. Most fistulas (37.8%) were diagnosed within 6 months or less from abscess drainage. Posterior fistulas were the most common, followed by anterior and left-sided fistulas.
Conclusion
The incidence of anal fistula in Bahrain after perianal abscess was 33.9%. Most of the patients who developed a fistula following pyogenic abscess drainage were males and above the age of 40 years. The most common site for fistula was posterior.
-
Citations
Citations to this article as recorded by

- Risk factors for perianal abscess recurrence after incision and drainage: a review of the literature
Kheira Gabsi
International Surgery Journal.2025; 12(2): 255. CrossRef - Anal Cryptoglandular Suppuration
Oladapo Akinmoladun, Quinton M. Hatch
Surgical Clinics of North America.2024; 104(3): 491. CrossRef - Proposal for a new classification of anorectal abscesses based on clinical characteristics and postoperative recurrence
Shan-Zhong Chen, Kui-Jun Sun, Yi-Fan Gu, Hong-Yuan Zhao, Dong Wang, Yun-Fang Shi, Ren-Jie Shi
World Journal of Gastrointestinal Surgery.2024; 16(11): 3425. CrossRef - Research Progress on Diagnosis and Surgical Treatment of Perianal Deep Space Abscess
永罡 秦
Advances in Clinical Medicine.2023; 13(01): 180. CrossRef
Case Report
Benign proctology,Complication,Surgical technique
- Rectal perforation and perirectal abscess following stapled hemorrhoidectomy for prolapsed hemorrhoids successfully managed with Endo-SPONGE endoluminal vacuum-assisted wound closure system
-
Emanuele Rosati, Manuel Valeri, Luigina Graziosi, Lavinia Amato, Stefano Avenia, Annibale Donini
-
Ann Coloproctol. 2022;38(5):387-390. Published online June 9, 2021
-
DOI: https://doi.org/10.3393/ac.2021.02.07
-
-
4,184
View
-
178
Download
-
1
Web of Science
-
1
Citations
-
Abstract
PDF
- Active drains, which work by negative pressure, are commonly used to drain closed airtight wounds. Higher negative pressure is used in vacuum-assisted wound closure dressings. Gastrointestinal leaks may be difficult to treat by surgical approach because of their association with high morbidity and mortality. Recently, endoscopic approaches have been applied with several degrees of success. Most recently, endoluminal vacuum-assisted wound closure (EVAC) has been employed with high success rates in decreasing both morbidity and mortality. In the present paper, the authors describe the successful use of Endo-SPONGE (B. Braun Medical B.V.) EVAC system therapy to drain an open rectal wound, following a perforation occurred during stapled hemorrhoidectomy.
-
Citations
Citations to this article as recorded by

- Endoluminal Vacuum Therapy (EVT) for the Treatment of Rectal Perforation Following Cleansing Enema Application
Alper Sozutek, Ekin Y Tas, Kemal Yener, Julia Ozcomert
Cureus.2023;[Epub] CrossRef
Original Article
Benign proctology
- Long-term outcomes after anal fistula surgery: results from two university hospitals in Thailand
-
Weeraput Chadbunchachai, Varut Lohsiriwat, Krisada Paonariang
-
Ann Coloproctol. 2022;38(2):133-140. Published online June 7, 2021
-
DOI: https://doi.org/10.3393/ac.2021.01.06
-
-
7,516
View
-
213
Download
-
4
Web of Science
-
3
Citations
-
Abstract
PDF
- Purpose
This study aimed to evaluate long-term outcomes after anal fistula surgery from university hospitals in Thailand.
Methods
A prospectively collected database of patients with cryptoglandular anal fistula undergoing surgery from 2011 to 2017 in 2 university hospitals was reviewed. Outcomes were treatment failure (persistent or recurrent fistula), fecal continence status, and chronic postsurgical pain.
Results
This study included 247 patients; 178 (72.1%) with new anal fistula and 69 (27.9%) with recurrent fistula. One hundred twenty-one patients (49.0%) had complex fistula; 53 semi-horseshoe (21.5%), 41 high transsphincteric (16.6%), 24 horseshoe (9.7%), and 3 suprasphincteric (1.2%). Ligation of intersphincteric fistula tract (LIFT) was the most common operation performed (n=88, 35.6%) followed by fistulotomy (n=79, 32.0%). With a median follow-up of 23 months (interquartile range, 12–45 months), there were 18 persistent fistulas (7.3%) and 33 recurrent fistulae (13.4%)—accounting for 20.6% overall failure. All recurrence occurred within 24 months postoperatively. Complex fistula was the only significant predictor for recurrent fistula with a hazard ratio of 4.81 (95% confidence interval, 1.82–12.71). There was no significant difference in healing rates of complex fistulas among seton staged fistulotomy (85.0%), endorectal advancement flap (72.7%), and LIFT (65.9%) (P=0.239). Four patients (1.6%) experienced chronic postsurgical pain. Seventeen patients (6.9%) reported worse fecal continence.
Conclusion
Overall failure for anal fistula surgery was 20.6%. Complex fistula was the only predictor for recurrent fistula. At least 2-year period of follow-up is suggested for detecting recurrent diseases and assessing patient-reported outcomes such as chronic pain and continence status.
-
Citations
Citations to this article as recorded by

- The Clinical Utility of Anorectal Manometry: A Review of Current Practices
Eleanor Aubrey Belilos, Zoë Post, Sierra Anderson, Mark DeMeo
Gastro Hep Advances.2025; 4(2): 100562. CrossRef - Exploring Health-Related Quality of Life in Patients with Anal Fistulas: A Comprehensive Study
Tudor Mateescu, Lazar Fulger, Durganjali Tummala, Aditya Nelluri, Manaswini Kakarla, Lavinia Stelea, Catalin Dumitru, George Noditi, Amadeus Dobrescu, Cristian Paleru, Ana-Olivia Toma
Life.2023; 13(10): 2008. CrossRef - Lower Fistula Recurrence with Pulling Seton: A Retrospective Cohort Study
Ahmad Izadpanah, Ali Reza Safarpour, Mohammad Rezazadehkermani, Ali Zahedian, Reza Barati-Boldaji
Shiraz E-Medical Journal.2022;[Epub] CrossRef
Case Reports
Benign proctology,Rare disease & stoma
- Extraperitoneal Spread of Anorectal Abscess: A Case Report and Literature Review
-
Papadopoulos S. Konstantinos, Dimopoulos Andreas, Kordeni Kleoniki, Filis Dimitrios
-
Ann Coloproctol. 2021;37(Suppl 1):S11-S14. Published online January 31, 2020
-
DOI: https://doi.org/10.3393/ac.2020.01.20
-
-
4,145
View
-
132
Download
-
3
Web of Science
-
3
Citations
-
Abstract
PDF
- Supralevator abscess is a rare form of anorectal disease responsible for very rare but morbid manifestations, one of which is superior spread through fascial planes. We present a rare case of a spreading anorectal abscess in a patient who presented with only diffuse abdominal pain, and we review similar cases in the literature according to anatomical considerations, presentation, diagnostic procedures, and treatment options. We identified 7 previously reported cases of spreading anorectal abscesses. Most abscesses had a horseshoe morphology, and all patients presented or developed abdominal pain. All patients had perianal swelling and pain. Five out of 7 patients were previously mistreated. Only 2 abscesses spread through both the pre- and retroperitoneal planes. Abdominal pain is a dominant feature of extraperitoneal inflammation originating from anorectal abscesses. The absence of perianal signs is rare, and proper inspection of the patient along with the medical history can lead to quicker diagnosis and decisive treatment.
-
Citations
Citations to this article as recorded by

- Perirectal Abscess with Anterior Extension to the Extraperitoneum and Space of Retzius: A Case Report
Hsiang Teng, Po-Hsien Wu
Medicina.2024; 60(2): 293. CrossRef - A Clinical-Anatomical-Radiological Study of Extraperitoneal Spaces: A Case Series
Giridhar Ashwath, Eshwar Kathiresan Manasijan, Logeshbalaji Seelampatti Palanisamy, Anthony P Rozario, Nachiket Shankar
Cureus.2024;[Epub] CrossRef - Complex Tunneling Perirectal Abscess: Intra-abdominal and Extraperitoneal Extension of a Persistent Perirectal Abscess
Abenezer S Tedla, Harsh R Parikh, Savni Satoskar, Jigyasha Pradhan, Shailja Kataria, Vinayak S Gowda
Cureus.2024;[Epub] CrossRef
Malignant disease,Rare disease & stoma
- Extensive Resection for Treatment of Locally Advanced Primary Mucinous Adenocarcinoma Arising From Fistula-in-Ano
-
Jordan Au, Francis M. Hulme-Moir, Andrew Herd, Mathew A. Kozman
-
Ann Coloproctol. 2021;37(Suppl 1):S7-S10. Published online November 26, 2019
-
DOI: https://doi.org/10.3393/ac.2019.11.19
-
-
3,416
View
-
97
Download
-
3
Web of Science
-
3
Citations
-
Abstract
PDF
- We report a case of a 66-year-old male who presented with a locally advanced primary mucinous adenocarcinoma arising from a fistula-in-ano. The presentation was typical for perianal sepsis and fistula-in-ano with anal pain and chronic discharge. Initial treatments with fistula debridement and seton were performed. Subsequent review of histology revealed underlying adenocarcinoma, while magnetic resonance imaging (MRI) showed local invasion into the prostate. The patient received neoadjuvant chemoradiotherapy followed by pelvic exenteration to maximize the chance of achieving cure. Features of this case are discussed together with its implications, including treatment guidelines and typical MRI findings.
-
Citations
Citations to this article as recorded by

- Perianal Mucinous Adenocarcinoma: A Case Report and a Systematic Review of the Literature
Ioannis D. Gkegkes, Vassilis Milionis, Nikolaos Goutas, Ioannis Mantzoros, Antonia A. Bourtzinakou, Apostolos P. Stamatiadis
Journal of Gastrointestinal Cancer.2025;[Epub] CrossRef - Perianal Mucinous Adenocarcinoma Found Incidentally From Perianal Mass
Seyed Khalafi, Malini Riddle, Brittany Harper, Vid Fikfak
Cureus.2023;[Epub] CrossRef - Advances in the Treatment of Colorectal Cancer with Peritoneal Metastases: A Focus on Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy
Youngbae Jeon, Eun Jung Park
The Ewha Medical Journal.2023;[Epub] CrossRef
Original Articles
- Efficacy of Plug Treatment for Complex Anorectal Fistulae: Long-term Danish Results
-
Melina Svraka Hansen, Monica Linda Kjær, Jens Andersen
-
Ann Coloproctol. 2019;35(3):123-128. Published online March 20, 2019
-
DOI: https://doi.org/10.3393/ac.2018.07.14
-
-
6,891
View
-
157
Download
-
8
Web of Science
-
9
Citations
-
Abstract
PDF
- Purpose
Bioprosthetic plugs are appealing, allow simple, repeatable applications, preserve sphincter integrity, minimize patient discomfort, and allow subsequent surgical options when needed. However, success rates vary widely. This study assessed the healing rate in our department when both the Cook-Surgisis and the Gore fistula plugs were used and the long-term effectiveness of using anal plugs for managing anal fistulae.
Methods
A chart review was performed for patients who had undergone plug insertion between January 2008 and December 2015 at Copenhagen University Hospital, Hvidovre. Data were collected through a prospectively collected database. Plugs were inserted according to guidance provided by 2 experienced surgeons. Long-term results were determined by clinical visits 3, 6, and 12 months after surgery and once yearly thereafter.
Results
From 2008 to 2015, 36 fistula plugs were inserted. During the follow-up period with a median duration of 18 months (range, 7–60 months), the fistulae of 52.8% of the patients healed. The plug failure rate was 44.4%, and the fistula recurrence rate was 26.3%. The median time to recurrence was 12 months. The overall success rate for plug treatment in our department was 39% when adjusted for recurrence.
Conclusion
The use of bioprosthetic plugs to treat patients with complex anal fistulae seems to be a safe, viable option for complex fistula repair when other surgical attempts have failed. However, it should not be the treatment of choice. Further prospective randomized studies with a sufficient sample-size and standardized measurements are necessary to evaluate the efficacy of fistula plugs fully.
-
Citations
Citations to this article as recorded by

- Application of biomaterials for complex anal fistulae
Daniel P. Fitzpatrick, Carmel Kealey, Damien Brady, Noel Gately
International Journal of Polymeric Materials and Polymeric Biomaterials.2023; 72(3): 204. CrossRef - Improved fistula plug outcome depends on the type of plug: a single‐centre retrospective study
Adele E Sayers, Matthew J Lee, Steve R Brown
Colorectal Disease.2023; 25(5): 995. CrossRef - Surgical treatment of anal fistula
A. Ya. Ilkanich, V. V. Darwin, E. A. Krasnov, F. Sh. Aliyev, K. Z. Zubailov
Сибирский научный медицинский журнал.2023; 43(5): 74. CrossRef - A Prospective, Single-Arm Study to Evaluate the Safety and Efficacy of RD2-Ver.02, an Autologous Blood Clot, in the Treatment of Anal Fistula
Edward Ram, Yaniv Zager, Dan Carter, Olga Saukhat, Roi Anteby, Ido Nachmany, Nir Horesh
Diseases of the Colon & Rectum.2023;[Epub] CrossRef - Impact du nombre de chirurgies antérieures sur la continence anale et la cicatrisation des fistules anales récidivantes
S.H. Emile, W. Khafagy, S.A. Elbaz
Journal de Chirurgie Viscérale.2022; 159(3): 219. CrossRef - Impact of number of previous surgeries on the continence state and healing after repeat surgery for recurrent anal fistula
S.H. Emile, W. Khafagy, S.A. Elbaz
Journal of Visceral Surgery.2022; 159(3): 206. CrossRef - Plug, Laser, videogestützte Behandlung von Analfisteln, Over-The-Scope-Clip, Stammzellen
Johannes Jongen, Jessica Scheider, Tilman Laubert, Volker Kahlke
coloproctology.2022; 44(1): 23. CrossRef - Comprehensive literature review of the applications of surgical laser in benign anal conditions
Ahmed Hossam Elfallal, Mohammad Fathy, Samy Abbas Elbaz, Sameh Hany Emile
Lasers in Medical Science.2022; 37(7): 2775. CrossRef - Ligation of intersphincteric fistula tract (LIFT) in treatment of anal fistula: An updated systematic review, meta-analysis, and meta-regression of the predictors of failure
Sameh Hany Emile, Sualeh Muslim Khan, Adeyinka Adejumo, Oyintonbra Koroye
Surgery.2020; 167(2): 484. CrossRef
- Rectourethral Fistula: Systemic Review of and Experiences With Various Surgical Treatment Methods
-
Ji Hye Choi, Byeong Geon Jeon, Sang-Gi Choi, Eon Chul Han, Heon-Kyun Ha, Heung-Kwon Oh, Eun Kyung Choe, Sang Hui Moon, Seung-Bum Ryoo, Kyu Joo Park
-
Ann Coloproctol. 2014;30(1):35-41. Published online February 28, 2014
-
DOI: https://doi.org/10.3393/ac.2014.30.1.35
-
-
6,229
View
-
115
Download
-
47
Web of Science
-
46
Citations
-
Abstract
PDF
- Purpose
A rectourethral fistula (RUF) is an uncommon complication resulting from surgery, radiation or trauma. Although various surgical procedures for the treatment of an RUF have been described, none has gained acceptance as the procedure of choice. The aim of this study was to review our experience with surgical management of RUF.
MethodsThe outcomes of 6 male patients (mean age, 51 years) with an RUF who were operated on by a single surgeon between May 2005 and July 2012 were assessed.
ResultsThe causes of the RUF were iatrogenic in four cases (two after radiation therapy for rectal cancer, one after brachytherapy for prostate cancer, and one after surgery for a bladder stone) and traumatic in two cases. Fecal diversion was the initial treatment in five patients. In one patient, fecal diversion was performed simultaneously with definitive repair. Four patients underwent staged repair after a mean of 12 months. Rectal advancement flaps were done for simple, small fistula (n = 2), and flap interpositions (gracilis muscle flap, n = 2; omental flap, n = 1) were done for complex or recurrent fistulae. Urinary strictures and incontinence were observed in patients after gracilis muscle flap interposition, but they were resolved with simple treatments. The mean follow-up period was 28 months, and closure of the fistula was achieved in all five patients (100%) who underwent definitive repairs. The fistula persisted in one patient who refused further definitive surgery after receiving only a fecal diversion.
ConclusionDepending on the severity and the recurrence status of RUF, a relatively simple rectal advancement flap repair or a more complex gracilis muscle or omental flap interposition can be used to achieve closure of the fistula.
-
Citations
Citations to this article as recorded by

- Complex case of granulomatosis with polyangiitis involving the urethra and prostate causing outflow obstruction and ano-urethral fistula
Mustafa Rashid, Adam Cox
Journal of Clinical Urology.2024; 17(1): 89. CrossRef - A rare case of fatal rectal perforation and sepsis following traumatic urinary catheterization
Darshan Sitharthan, Paul Sved
Urology Case Reports.2024; 54: 102706. CrossRef - Gracilis muscle interposition for complex perineal fistulas: A systematic review and meta‐analysis of the literature
Zoe Garoufalia, Rachel Gefen, Sameh Hany Emile, Emanuela Silva‐Alvarenga, Nir Horesh, Michael R. Freund, Steven D. Wexner
Colorectal Disease.2023; 25(4): 549. CrossRef - Outcomes of gracilis muscle interposition for rectourethral fistulas caused by treatment of prostate cancer
S. H. Emile, N. Horesh, V. Strassmann, Z. Garoufalia, R. Gefen, P. Zhou, E. Ray-Offor, G. Dasilva, S. D. Wexner
Techniques in Coloproctology.2023; 27(10): 937. CrossRef - Case report on a rare complication after transanal total mesorectal excision (TaTME) for rectal malignancy vesicorectal fistula
Sapphire Melody Ho, Kishore Rajaguru, Jing Yu Ng, Choon Sheong Seow
International Journal of Surgery Case Reports.2023; 105: 108009. CrossRef - Laparoscopic repair of acquired rectourethral fistula by vesical peritoneal flap
Christian Mouawad, Elie El Helou, Houssam Dahboul, Rhea Akel, Bilal Chamaa, Rany Aoun, Serge Kassar, Michael Osseis, Roger Noun, Ghassan Chakhtoura
Asian Journal of Endoscopic Surgery.2023; 16(4): 814. CrossRef - Pelvic Extirpative Surgery for the “End-Stage Irradiated Bladder”
Nikolas Moring, Seamus Barrett, Andrew C. Peterson, Brian M. Inouye
Cancers.2023; 15(17): 4238. CrossRef - Radiation-induced recto-urinary fistula: A dreaded complication with devastating consequences
Kyeong Ri Yu, Lucas Keller-Biehl, Leon Smith-Harrison, Sarah Z. Hazell, William R. Timmerman, Jeannie F. Rivers, Thomas A. Miller
Surgery in Practice and Science.2023; 15: 100216. CrossRef - Gracilis muscle flap combined with a laparoscopic transabdominal approach is effective in the treatment of post-prostatectomy rectourethral fistula: A case report
Tomohiro Takeda, Tatsuya Shonaka, Chikayoshi Tani, Toshihiko Hayashi, Hidehiro Kakizaki, Yasuo Sumi
International Journal of Surgery Case Reports.2022; 92: 106856. CrossRef - Effectiveness of York-Mason Procedure for a Refractory Rectourethral Fistula that Relapsed after Repair by a Perineal Approach:A Case Report
Masatsugu Kojima, Toru Miyake, Tomoyuki Ueki, Tomoharu Shimizu, Masaji Tani
Nippon Daicho Komonbyo Gakkai Zasshi.2022; 75(6): 297. CrossRef - Robotic-Assisted Lower Genitourinary Tract Reconstruction
Alex J. Xu, Kirtishri Mishra, Yeonsoo S. Lee, Lee Cheng Zhao
Urologic Clinics of North America.2022; 49(3): 507. CrossRef - Rectal Perforation During Pelvic Surgery
Bernardo Rocco, Gaia Giorgia, Assumma Simone, Calcagnile Tommaso, Sangalli Mattia, Terzoni Stefano, Eissa Ahmed, Bozzini Giorgio, Bernardino De Concilio, Antonio Celia, Micali Salvatore, Maria Chiara Sighinolfi
European Urology Open Science.2022; 44: 54. CrossRef - Preventing Rectourethral Fistula Recurrence With Gracilis Flap
Keon Min Park, Yenny Y. Rosli, Allen Simms, Rachel Lentz, Deepak R. Bharadia, Benjamin Breyer, William Y. Hoffman
Annals of Plastic Surgery.2022; 88(4): S316. CrossRef - Validating the Martini Staging System for Rectourethral Fistula: A Meta-Analysis of Postoperative Outcomes
Kirtishri Mishra, Amr Mahran, Bissan Abboud, Laura Bukavina, Ahmed Elshafei, Al Ray, Austin Fernstrum, Rayan Abboud, Mohammed Elgammal, Lee C. Zhao, Shubham Gupta
Urology.2021; 147: 299. CrossRef - Rectourethral Fistula Repair With Endorectal Advancement Flap and Implantation of Biologic Mesh
Tae David Kim, Gerald Gantt, Kunal Kochar, Slawomir Marecik, John J. Park
Diseases of the Colon & Rectum.2021; 64(1): e1. CrossRef - Clinical outcome and quality of life after gracilis muscle transposition for fistula closure over a 10-year period
M. Grott, A. Rickert, S. Hetjens, P. Kienle
International Journal of Colorectal Disease.2021; 36(3): 569. CrossRef - Urorectal fistula repair using different approaches: operative results and quality of life issues
Javier C. Angulo, Ignacio Arance, Yannick Apesteguy, João Felicio, Natália Martins, Francisco E. Martins
International braz j urol.2021; 47(2): 399. CrossRef - Robotic transanal rectourethral fistula repair—a video vignette
Thomas Surya Suhardja, Belinda Errington, Amirala Khalessi, Kim‐Chi Phan‐Thien
Colorectal Disease.2021; 23(5): 1275. CrossRef - Tratamiento de las fístulas uretrorrectales tras prostatectomía radical mediante la interposición de material biológico vía perineal
J.U. Juan Escudero, F. Villalba Ferrer, M. Ramos de Campos, M. Fabuel Deltoro, M.J. García Coret, F. Sánchez Ballester, I. Povo Martín, Y. Pallas Costa, P. Pardo Duarte, J. García Ibañez, A. Monzó Cataluña, K. Rechi Sierra, C. Juliá Romero, E. López Alcin
Actas Urológicas Españolas.2021; 45(5): 398. CrossRef - Treatment for rectourethral fistulas after radical prostatectomy with biological material interposition through a perineal access
J.U. Juan Escudero, F. Villaba Ferrer, M. Ramos de Campos, M. Fabuel Deltoro, M.J. Garcia Coret, F. Sanchez Ballester, I. Povo Martín, Y. Pallas Costa, P. Pardo Duarte, J. García Ibañez, A. Monzó Cataluña, K. Rechi Sierra, C. Juliá Romero, E. Lopez Alcina
Actas Urológicas Españolas (English Edition).2021; 45(5): 398. CrossRef - A Curious Case of Rectal Ejaculation
Frank L Ventura, Christopher M Nguyen, Alexander Dang, Michelle Baliss, Lindsay K Sonstein
Cureus.2021;[Epub] CrossRef - Adverse Features of Rectourethral Fistula Requiring Extirpative Surgery and Permanent Dual Diversion: Our Experience and Recommendations
Francisco E. Martins, João Felicio, Tiago Ribeiro Oliveira, Natália Martins, Vítor Oliveira, Artur Palmas
Journal of Clinical Medicine.2021; 10(17): 4014. CrossRef - Fistelchirurgie
C. M. Rosenbaum, M. W. Vetterlein, M. Fisch
Der Urologe.2020; 59(4): 489. CrossRef - Conservative treatment of rectovesical fistula after leakage following laparoscopic radical resection of rectal cancer
Shunli Yan, Huimin Sun, Zhaohui Li, Shuaifeng Liu, Baowei Han
Journal of International Medical Research.2020;[Epub] CrossRef - A rare case of tubercular recto-prostatic urethral fistula with tuberculous orchitis
Niramya Pathak, Mohan Keshavamurthy, Karthik Rao, Shakir Tabrez, Mohan Balaiah Ashwathaiya, Premakumar Krishnappa
Urology Case Reports.2020; 33: 101355. CrossRef - Minimally invasive perineal redo surgery for rectovesical and rectovaginal fistulae: A case series
A.A.J. Grüter, S.E. Van Oostendorp, L.J.H. Smits, M. Kusters, M. Özer, J.A. Nieuwenhuijzen, J.B. Tuynman
International Journal of Surgery Case Reports.2020; 77: 733. CrossRef - Iatrogenic bowel injury (early vs delayed)
Elyse Leevan, Joseph C. Carmichael
Seminars in Colon and Rectal Surgery.2019; 30(3): 100688. CrossRef - Management of acquired rectourethral fistulas in adults
Shulian Chen, Rang Gao, Hong Li, Kunjie Wang
Asian Journal of Urology.2018; 5(3): 149. CrossRef - The Place of Transanal Endoscopic Surgery in the Treatment of Rectourethral Fistula
Xavier Serra-Aracil, Meritxell Labró-Ciurans, Laura Mora-López, Jesús Muñoz-Rodríguez, Raúl Martos-Calvo, Joan Prats-López, Salvador Navarro-Soto
Urology.2018; 111: 139. CrossRef - A Case of Rectourethal Fistula Caused by a Urethral Foreign Body
Nobuyuki OKAMOTO, Norimitsu SHIMADA, Raita YANO, Yusuke WATADANI, Hiroki OHGE, Taijiro SUEDA
Nihon Rinsho Geka Gakkai Zasshi (Journal of Japan Surgical Association).2017; 78(8): 1900. CrossRef - Diagnosis and Treatments for Vesico-Enteric Fistulas: a 2017 Current Review
Justin W. Fincher, Ehab Eltahawy
Current Bladder Dysfunction Reports.2017; 12(3): 212. CrossRef - Management of radiation-induced rectovesical fistula in a woman using ileum
Qiqi Mao, Jindan Luo, Jiajie Fang, Hai Jiang
Medicine.2017; 96(46): e8553. CrossRef - Treatment Efficacy of Different Surgical Procedures for Postoperative Residual Rectourethral Fistula Following Anoplasty
Tingchong Zhang, Wei Chen, Wenbo Pang, Chunhui Peng, Yajun Chen, Jinzhe Zhang
International Surgery.2017; 102(11-12): 560. CrossRef - Rectourethral fistula reconstruction in elderly patients
Nirmish Singla, Allen F. Morey
Current Opinion in Urology.2016; 26(2): 171. CrossRef - Rectourethral fistula: A challenging management problem
Michael Stamatakos, K. Ntzeros, G. Christis, F. Anyfanti, S. Sotirianakos
Hellenic Journal of Surgery.2016; 88(4): 257. CrossRef - Diagnosis and Surgical Management of Uroenteric Fistula
Harcharan S. Gill
Surgical Clinics of North America.2016; 96(3): 583. CrossRef - Minimally invasive treatment of rectovesical fistula: A case report
Alba Manuel Vázquez, Francisco Javier Jiménez Miramón, José Luis Ramos Rodríguez, José María Jover Navalón
Revista Española de Enfermedades Digestivas.2016;[Epub] CrossRef - Abordaje perineal de fístulas rectouretrales tras prostatectomía radical laparoscópica
J. Guimerà-García, E. Pieras-Ayala, J.P. Burgués-Gasion, M. Ozonas-Moragues, V. Tubau-Vidaña, P. Piza-Reus
Actas Urológicas Españolas.2016; 40(2): 119. CrossRef - Unusual Case of Urethrorectal Fistula in Adolescence in a Patient with a History of Congenital Anorectal Malformation
Constantinos Nastos, Ira Sotirova, Athanasios Papatsoris, Andreas Skolarikos, Ioannis Papaconstantinou, Athanasios Dellis
Journal of Endourology Case Reports.2016; 2(1): 24. CrossRef - Perineal approach for rectourethral fistulae after radical laparoscopic prostatectomy
J. Guimerà García, E. Pieras Ayala, J.P. Burgués Gasion, M. Ozonas Moragues, V. Tubau Vidaña, P. Piza Reus
Actas Urológicas Españolas (English Edition).2016; 40(2): 119. CrossRef - Testicular Interposition Flap for Repair of Perineal Urinary Fistulae: A Novel Surgical Technique
Valary T. Raup, Jairam R. Eswara, Stephen D. Marshall, Steven B. Brandes
Case Reports in Urology.2015; 2015: 1. CrossRef - Fístulas recto-uretrales adquiridas: etiopatogenia, diagnóstico y opciones terapéuticas
Carlos Cerdán Santacruz, Javier Cerdán Miguel
Cirugía Española.2015; 93(3): 137. CrossRef - A review of rectal toxicity following permanent low dose-rate prostate brachytherapy and the potential value of biodegradable rectal spacers
M E Schutzer, P F Orio, M C Biagioli, D A Asher, H Lomas, D Moghanaki
Prostate Cancer and Prostatic Diseases.2015; 18(2): 96. CrossRef - Acquired Recto-Uretral Fistulas: Etiopathogenesis, Diagnosis and Therapeutic Options
Carlos Cerdán Santacruz, Javier Cerdán Miguel
Cirugía Española (English Edition).2015; 93(3): 137. CrossRef - Surgical Treatment of Rectourinary Fistulas: Review of the Literature
Alessandro Crestani, Fabrizio Dal Mora
Urologia Journal.2015; 82(1): 30. CrossRef - Individualized Treatment for a Rectourethral Fistula: Rare Complications
In Ja Park
Annals of Coloproctology.2014; 30(1): 7. CrossRef
Review
- New Techniques for Treating an Anal Fistula
-
Kee Ho Song
-
J Korean Soc Coloproctol. 2012;28(1):7-12. Published online February 29, 2012
-
DOI: https://doi.org/10.3393/jksc.2012.28.1.7
-
-
13,861
View
-
122
Download
-
19
Citations
-
Abstract
PDF
Surgery for an anal fistula may result in recurrence or impairment of continence. The ideal treatment for an anal fistula should be associated with low recurrence rates, minimal incontinence and good quality of life. Because of the risk of a change in continence with conventional techniques, sphincter-preserving techniques for the management complex anal fistulae have been evaluated. First, the anal fistula plug is made of lyophilized porcine intestinal submucosa. The anal fistula plug is expected to provide a collagen scaffold to promote tissue in growth and fistula healing. Another addition to the sphincter-preserving options is the ligation of intersphincteric fistula tract procedure. This technique is based on the concept of secure closure of the internal opening and concomitant removal of infected cryptoglandular tissue in the intersphincteric plane. Recently, cell therapy for an anal fistula has been described. Adipose-derived stem cells have two biologic properties, namely, ability to suppress inflammation and differentiation potential. These properties are useful for the regeneration or the repair of damaged tissues. This article discusses the rationales for, the estimated efficacies of, and the limitations of new sphincter-preserving techniques for the treatment of anal fistulae.
-
Citations
Citations to this article as recorded by

- Sensitivity of Diffusion-Weighted Image Combined with T2 Turbo Inversion Recovery Magnitude Sequence and as an Alternative to Contrast-Enhanced MRI in the Detection of Perianal Fistula
Noor Fadhil Baqir, Rasha Sabeeh Ahmed, Khaleel Ibraheem Mohsen
Advanced Engineering Research (Rostov-on-Don).2023; 23(3): 307. CrossRef - A PILOT STUDY on the Clinical and Functional Outcomes of an Improvised Technique of Core-cut Fistulectomy for Fistula-in-ano
Masoom Parwez, Tanweerul Huda, Moorat S. Yadav, Kamal Gupta, Kushal Mital, Bharati Pandya
Surgical Innovation.2022; 29(3): 426. CrossRef - Diagnostic Accuracy of Magnetic Resonance Imaging in Detection of Perianal Fistula keeping Surgical Findings as Gold Standard
Haider Ali, Uzma Azmat, Manoj Kumar , Khadijah Abid
Pakistan Journal of Health Sciences.2022; : 181. CrossRef - Surgical technique: an improvisation in application of the technique of core-cut fistulectomy for fistula-in-ano
Masoom Parwez, Tanweerul Huda, Kushal Mital, Bharati Pandya
Journal of Surgical Case Reports.2021;[Epub] CrossRef - External sphincter-sparing anal fistulotomy (ESSAF): a simplified technique for the treatment of fistula-in-ano
S. Y. Parnasa, B. Helou, I. Mizrahi, R. Gefen, M. Abu-Gazala, A. J. Pikarsky, N. Shussman
Techniques in Coloproctology.2021; 25(12): 1311. CrossRef - Management of transsphincteric fistula-in-ano by modified conventional Ksharasutra therapy
Khusboo Faridi, P. Sreenadh, Vyasadeva Mahanta, Rahul Sherkhane
Journal of Ayurveda Case Reports.2021; 4(3): 95. CrossRef - Video-Assisted Anal Fistula Treatment (VAAFT) for complex anorectal fistula: efficacy and risk factors for failure at 3-year follow-up
L. Regusci, F. Fasolini, P. Meinero, G. Caccia, G. Ruggeri, M. Serati, A. Braga
Techniques in Coloproctology.2020; 24(7): 741. CrossRef - Video-assisted Treatment of Rectal Fistulas: the Experience and Treatment Results
Vitalii S. Groshilin, Viktoria G. Brizhak, Evgeny Y. Khoronko, Petr V. Tsygankov, Yuri V. Khoronko
Lietuvos chirurgija.2020; 19(1-2): 27. CrossRef - Innovative Use of Endotracheal Tube to Find Out Internal Opening in Fistula in Ano
Anil Kumar, Ajeet Kumar, Bindey Kumar, Shiv Kishor
SN Comprehensive Clinical Medicine.2019; 1(9): 712. CrossRef - Ayurvedic Management of Fistula in Ano
KM Pratap Shankar, GN SreeDeepthi, Rohit KS, GK Swamy
Journal of Research in Ayurvedic Sciences.2019; 3(3): 100. CrossRef - Decellularized and matured esophageal scaffold for circumferential esophagus replacement: Proof of concept in a pig model
Guillaume Luc, Guillaume Charles, Caroline Gronnier, Magali Cabau, Charlotte Kalisky, Mallory Meulle, Reine Bareille, Samantha Roques, Lionel Couraud, Johanna Rannou, Laurence Bordenave, Denis Collet, Marlène Durand
Biomaterials.2018; 175: 1. CrossRef - Ligation of the intersphincteric fistula tract procedure and its modifications
Ahmed Mohamed Elsayed Metwalli Ali Gendia, Mahmmad Ahmad Abd-erRazik, Hanna Habib Hanna
Journal of Coloproctology.2018; 38(04): 324. CrossRef - High ligation of the anal fistula tract by lateral approach: A prospective cohort study on a modification of the ligation of the intersphincteric fistula tract (LIFT) technique
Wook Ho Kang, Hyung Kyu Yang, Han Jeong Chang, Yong Taek Ko, Byung Eun Yoo, Cheong Ho Lim, Jae Kwan Hwang, Young Chan Lee, Hyeon Keun Shin, Hae Jung Son
International Journal of Surgery.2018; 60: 9. CrossRef - S3-Leitlinie: Kryptoglanduläre Analfisteln
A. Ommer, A. Herold, E. Berg, S. Farke, A. Fürst, F. Hetzer, A. Köhler, S. Post, R. Ruppert, M. Sailer, T. Schiedeck, O. Schwandner, B. Strittmatter, B. H. Lenhard, W. Bader, S. Krege, H. Krammer, E. Stange
coloproctology.2017; 39(1): 16. CrossRef - What happens after a failed LIFT for anal fistula?
Moriah Wright, Alan Thorson, Garnet Blatchford, Maniamparampil Shashidharan, Jennifer Beaty, Noelle Bertelson, Piyush Aggrawal, Lindsay Taylor, Charles A. Ternent
The American Journal of Surgery.2017; 214(6): 1210. CrossRef - Fistula tract curettage and the use of biological dermal plugs improve high transsphincteric fistula healing in an animal model
Cigdem Benlice, Merve Yildiz, Semih Baghaki, Ilknur Erguner, Deniz Cebi Olgun, Sebnem Batur, Sibel Erdamar, Pinar Ambarcioglu, Ismail Hamzaoglu, Tayfun Karahasanoglu, Bilgi Baca
International Journal of Colorectal Disease.2016; 31(2): 291. CrossRef - Management of complex anorectal fistulas with seton drainage plus partial fistulotomy and subsequent ligation of intersphincteric fistula tract (LIFT)
B. Schulze, Y.-H. Ho
Techniques in Coloproctology.2015; 19(2): 89. CrossRef - New Techniques in Anal Fistula Management
Rasoul Azizi, Saman Mohammadipour
Annals of Colorectal Research.2014;[Epub] CrossRef - Adipose-Derived Stem Cells in Tissue Regeneration: A Review
Patricia Zuk
ISRN Stem Cells.2013; 2013: 1. CrossRef
Case Report
- Levator Ani Muscle Posterior Midline Incision Method for Diffrentiation of Anal Fistulas Involving Ischioretal and Pelvirectal Spaces.
-
Lim, Seok Won
-
J Korean Soc Coloproctol. 2008;24(1):72-74.
-
DOI: https://doi.org/10.3393/jksc.2008.24.1.72
-
-
Abstract
PDF
- The difference between anal fistulas involving the ischioretal space and pelvirectal space is that in the former the involvement of the anal fistula is low the levator ani muscle whereas in the latter it is above the levator ani muscle. The levator ani muscle posterior midline incision method, which is introduced here, is thought not to injure the anal sphincter; thus, it does not affect the anal function. The method also allow the surgeon to assess readily and accurately whether or not the fistula has invaded the pelvirectal space.