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Fecal Diversion in Reconstructive Pelvic Surgery

Fecal diversion serves as a critical adjunctive or definitive intervention across rectovaginal, rectourethral, and complex entero-urinary fistulae, Fournier's gangrene, complex perineal wound management, and refractory fecal incontinence.[1][2][3] It can be a temporary measure that facilitates definitive repair or, particularly after radiation or in refractory Crohn's, a permanent solution when reconstruction is not feasible. Both loop ileostomy and loop colostomy are effective for diversion (ASCRS 2022 strong recommendation, 1B); the choice is driven by the relevant complication profile rather than diversion efficacy.[24]

Indications​

1. Rectovaginal Fistula (RVF)​

  • Adjunct to complex repair — diverting ostomy commonly added to Martius and gracilis interposition (63–100% of these cases), although evidence for outcome benefit is weak.[1]
  • Anastomotic-related RVF — recommended as the initial step; ~37% of anastomotic RVFs heal with diversion alone.[1]
  • Recurrent / multiply operated RVF — Obi 2026 (n = 158): 63.3% underwent diversion; number of prior repairs is the strongest predictor of diversion use.[4]
  • Failed first repair — Fu 2019: 10/10 healed with stoma vs 0/0 without (P = 0.02).[5]
  • Radiation-induced RVF — diverting colostomy is often the primary intervention; only ~12% heal with diversion alone. Laparoscopic diverting colostomy is feasible even with prior XRT and adhesions, with shorter LOS and fewer SSIs than open.[6]
  • Crohn's RVF — independent factor for success in per-procedure analysis (OR 3.5, P = 0.009).[7]

2. Rectourethral Fistula (RUF)​

  • Pre-repair diversion — most patients undergo temporary fecal + urinary diversion before definitive repair (Beddy 2013: 30/50).[8]
  • Non-radiated RUF — primary repair 80–100%; ostomy reversal 91–97%.[9][10]
  • Radiation-induced RUF — outcomes dramatically worse: 83–86% require permanent colostomy, 93–100% require permanent urinary diversion, and only 0–50% achieve successful primary fistula repair.[8][11][12]
  • Lo Re 2026 SR (> 500 patients) — transperineal repair with gracilis interposition is the dominant technique; irradiated patients frequently require additional surgeries or permanent diversion.[13]

3. Complex Entero-Urinary Fistulae​

Shackley 2000 staged multidisciplinary protocol — proximal defunctioning + distal drainage of GI and urinary tracts, nutritional / sepsis recovery, then delayed reconstruction — 100% success in 10 complex cases at mean 5 mo to reconstruction.[3]

4. Fournier's Gangrene​

  • Required in 22–34% of Fournier's admissions.[14][15]
  • Indications: anal-sphincter involvement, fecal incontinence, ongoing fecal contamination of the wound.[16]
  • WSES-AAST 2021 — multidisciplinary, tailored approach; postpone the stoma decision ≥ 48 h from initial surgery to allow inflammation / edema regression for proper sphincter assessment.[16]
  • Sarofim 2021 meta-analysis (n = 1,482) — mortality higher with stoma (OR 1.71, P = 0.01); likely selection bias for more severe disease.[17]
  • Non-invasive alternative first — Flexi-Seal fecal management system; surgical diversion postponed as long as possible.[14]
  • Diversion may reduce further debridement, shorten time to wound healing, and facilitate skin graft / flap uptake.[18]

5. Complex Perineal Wound Management​

  • Trauma, burns, pressure injury — diversion prevents wound contamination.[19]
  • Fecal management systems (Flexi-Seal) — less-invasive alternative when surgical candidacy is poor.[20]
  • Kudsk & Hanna protocol for complex perineal trauma — sigmoidoscopy + diverting colostomy + distal rectal washout + radical debridement reduced pelvic sepsis from 40–80% to 0%.[19]

6. Refractory Fecal Incontinence​

  • Last-resort colostomy for FI refractory to all other treatments — ACOG: should be performed only by urogynecologists or other subspecialists familiar with the procedure.[2]
  • ASCRS 2023: option for patients who have failed or do not wish to pursue other therapies.[21]
  • Despite QoL concerns, 83–84% of FI patients with a colostomy report significant lifestyle improvement and would choose it again.[21][22]
  • FIQOL: better coping (2.7 vs 2.0, P = 0.005) and embarrassment (2.7 vs 2.2, P = 0.01) scores than living with FI.[21]

Types of Fecal Diversion​

TypeAdvantagesDisadvantagesBest indication
Loop ileostomyLower prolapse (4% vs 16%), lower parastomal herniaHigher dehydration (60% vs 11% of readmissions), more pouching issues (68% vs 43%), higher readmission (OR 3.15)Protecting pelvic anastomoses, temporary diversion[23][24]
Loop colostomyLower dehydration risk, fewer pouching issues, lower readmissionHigher prolapse (16% vs 4%), higher revision (12% vs 4%), higher SSI at closurePerineal-wound protection, Fournier's gangrene, radiation-induced fistulas[23][24]
End colostomyComplete fecal diversion, definitivePermanent, more complex reversalPermanent diversion (APR, proctectomy)[3]
Fecal management system (Flexi-Seal)Non-invasive, no surgery requiredShort-term only (intra-rectal damage risk), incomplete diversionFournier's, perianal wounds, ICU patients[14][20]

ASCRS 2022 ostomy guideline: both loop ileostomy and loop colostomy are effective for diversion (Strong, 1B); main differences are complication profile, not diversion efficacy.[24]

Loop ileostomy vs loop colostomy — Arndt 2026 (n = 515)​

  • Readmissions — ileostomy 23% vs colostomy 13% (P = 0.013); ileostomy independent OR 3.15 for readmission.[23]
  • Dehydration — 60% of ileostomy readmissions vs 11% of colostomy readmissions (P < 0.001).[23]
  • Pouching issues — 68% ileostomy vs 43% colostomy.[23]
  • Stomal prolapse — 4% ileostomy vs 16% colostomy.[23]

Effect on Fistula Healing​

EtiologyHealing with diversion alone
RVF, anastomotic37%[1]
RVF, radiation-induced12%[6]
Crohn's perianalInitial response 64%; sustained remission 26–50%; ultimately 42% require proctectomy; reversal attempted in only 34.5% and successful in only 17%[1]
RVF (all causes), Corte multivariateIndependent predictor of per-procedure success (OR 3.5) alongside major procedure and early surgery[7]

Stoma Reversal Rates​

IndicationReversal attemptedSuccessful reversalPermanent stoma rate
Non-radiated RUF91–97%91–100%0–9%[9][10]
Radiated RUF17–45%Variable83–86%[8][11][12]
Crohn's perianal34.5%17%42% proctectomy + others[1][26]
RVF, post-anastomoticMost~37% heal with diversion aloneVariable[1]
Fournier's gangreneVariableLow in many series22% required colostomy[14][27]

Becker 2025 — long-term Crohn's perianal-disease defunctioning (median follow-up 90 mo): only 21% underwent reversal attempt, with successful closure in 9 of 53. Reversal associated with fistula closure.[26]

Complications​

  • Stoma-related — prolapse, retraction, parastomal hernia, peristomal skin irritation, high-output stoma, dehydration (especially ileostomy)[23][24]
  • Reversal-related — SSI up to 40%, anastomotic leak, incisional hernia, postoperative ileus (more after ileostomy closure)[24][28]
  • Mortality — ~2% for colostomy creation in the FI population[22]
  • Psychological — body image, social restriction, appliance management; many patients still report better QoL than living with fistula or FI[21]
  • Non-reversal — significant proportion of "temporary" diversions become permanent, particularly in Crohn's (42% proctectomy) and radiation-induced fistulas[1][26]

Quality of Life​

  • Colostomy for FI — higher SF-36 social function and better FIQOL coping / embarrassment / lifestyle scores than living with FI.[21][22]
  • 84% of FI patients with colostomy would choose it again.[21]
  • Radiation RVF — proctectomy + diverting stoma yields superior symptom relief (less tenesmus, less anal discharge) than diversion alone at 6 and 12 mo.[1]
  • Fournier's gangrene — psychological impact of the stoma was not a major patient concern in one review.[18]

Key Takeaways​

  • Most commonly employed for pelvic fistula management (RVF, RUF, entero-urinary), Fournier's gangrene, and refractory FI.
  • Selective use in high-risk patients (recurrent fistulas, interposition flap repairs, radiation-induced fistulas) may equalize outcomes with non-diverted patients.
  • Both loop ileostomy and loop colostomy are effective; choose by complication profile relevant to the patient.
  • A significant proportion of "temporary" diversions become permanent, particularly in Crohn's and radiation-induced fistulas — counsel accordingly.
  • Non-invasive fecal management systems should be considered first when appropriate, particularly in Fournier's.
  • The first repair is the best chance of success for pelvic fistulas — fecal diversion becomes more important with each subsequent repair attempt.

References​

1. 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

2. ACOG Committee on Practice Bulletins—Gynecology. "ACOG practice bulletin no. 210: fecal incontinence." Obstet Gynecol. 2019;133(4):e260–e273. doi:10.1097/AOG.0000000000003187

3. Shackley DC, Brew CJ, Bryden AA, et al. "The staged management of complex entero-urinary fistulae." BJU Int. 2000;86(6):624–629. doi:10.1046/j.1464-410x.2000.00871.x

4. Obi M, Kanters A, Spivak AR, et al. "Factors associated with fecal diversion prior to rectovaginal fistula repair." J Gastrointest Surg. 2026:102442. doi:10.1016/j.gassur.2026.102442

5. Fu J, Liang Z, Zhu Y, Cui L, Chen W. "Surgical repair of rectovaginal fistulas: predictors of fistula closure." Int Urogynecol J. 2019;30(10):1659–1665. doi:10.1007/s00192-019-04082-w

6. Liu Z, Ren L, Zhang J, Guo D. "Surgical outcomes in laparoscopic vs open diverting colostomy for radiation-related rectovaginal fistula." Med Sci Monit. 2025;31:e947487. doi:10.12659/MSM.947487

7. Corte H, Maggiori L, Treton X, et al. "Rectovaginal fistula: what is the optimal strategy? An analysis of 79 patients undergoing 286 procedures." Ann Surg. 2015;262(5):855–860. doi:10.1097/SLA.0000000000001461

8. Beddy D, Poskus T, Umbreit E, et al. "Impact of radiotherapy on surgical repair and outcome in patients with rectourethral fistula." Colorectal Dis. 2013;15(12):1515–1520. doi:10.1111/codi.12350

9. Vanni AJ, Buckley JC, Zinman LN. "Management of surgical and radiation-induced rectourethral fistulas with an interposition muscle flap and selective buccal mucosal onlay graft." J Urol. 2010;184(6):2400–2404. doi:10.1016/j.juro.2010.08.004

10. Hanna JM, Turley R, Castleberry A, et al. "Surgical management of complex rectourethral fistulas in irradiated and nonirradiated patients." Dis Colon Rectum. 2014;57(9):1105–1112. doi:10.1097/DCR.0000000000000175

11. Linder BJ, Umbreit EC, Larson D, et al. "Effect of prior radiotherapy and ablative therapy on surgical outcomes for the treatment of rectourethral fistulas." J Urol. 2013;190(4):1287–1291. doi:10.1016/j.juro.2013.03.077

12. Martins FE, Felicio J, Oliveira TR, et al. "Adverse features of rectourethral fistula requiring extirpative surgery and permanent dual diversion: our experience and recommendations." J Clin Med. 2021;10(17):4014. doi:10.3390/jcm10174014

13. Lo Re M, Pezzoli M, Garcia Rojo E, et al. "A systematic review on the surgical management of acquired rectourethral fistula." Int J Impot Res. 2026;38(3):214–225. doi:10.1038/s41443-025-01100-y

14. Ortega Ferrete A, López E, Juez Sáez LD, et al. "Fournier's gangrene and fecal diversion. When, in which patients, and what type should I perform?" Langenbecks Arch Surg. 2023;408(1):428. doi:10.1007/s00423-023-03137-3

15. Furr J, Watts T, Street R, et al. "Contemporary trends in the inpatient management of Fournier's gangrene: predictors of length of stay and mortality based on population-based sample." Urology. 2017;102:79–84. doi:10.1016/j.urology.2016.09.021

16. Tarasconi A, Perrone G, Davies J, et al. "Anorectal emergencies: WSES-AAST guidelines." World J Emerg Surg. 2021;16(1):48. doi:10.1186/s13017-021-00384-x

17. Sarofim M, Di Re A, Descallar J, Toh JWT. "Relationship between diversional stoma and mortality rate in Fournier's gangrene: a systematic review and meta-analysis." Langenbecks Arch Surg. 2021;406(8):2581–2590. doi:10.1007/s00423-021-02175-z

18. Huang S, Chen DC, Perera M, Lawrentschuk N. "Role of diverting colostomy and reconstruction in managing Fournier's gangrene — a narrative review." BJU Int. 2024;134(4):534–540. doi:10.1111/bju.16365

19. Kudsk KA, Hanna MK. "Management of complex perineal injuries." World J Surg. 2003;27(8):895–900. doi:10.1007/s00268-003-6719-z

20. Yu YS, Weng YT, Wu CW, Tzeng YS. "Successful perianal wound treatment using the fecal management system: a report of 2 cases." Ann Plast Surg. 2025;94(3S Suppl 1):S87–S89. doi:10.1097/SAP.0000000000004197

21. Bordeianou LG, Thorsen AJ, Keller DS, et al. "The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of fecal incontinence." Dis Colon Rectum. 2023;66(5):647–661. doi:10.1097/DCR.0000000000002776

22. Bharucha AE, Rao SSC, Shin AS. "Surgical interventions and the use of device-aided therapy for the treatment of fecal incontinence and defecatory disorders." Clin Gastroenterol Hepatol. 2017;15(12):1844–1854. doi:10.1016/j.cgh.2017.08.023

23. Arndt KR, Papadimatos S, Allar BG, et al. "Complications and readmissions in diverting loop ileostomies and loop colostomies." Dis Colon Rectum. 2026;69(5):826–835. doi:10.1097/DCR.0000000000004156

24. Davis BR, Valente MA, Goldberg JE, et al. "The American Society of Colon and Rectal Surgeons clinical practice guidelines for ostomy surgery." Dis Colon Rectum. 2022;65(10):1173–1190. doi:10.1097/DCR.0000000000002498

25. Du R, Zhou J, Tong G, et al. "Postoperative morbidity and mortality after anterior resection with preventive diverting loop ileostomy versus loop colostomy for rectal cancer: an updated systematic review and meta-analysis." Eur J Surg Oncol. 2021;47(7):1514–1525. doi:10.1016/j.ejso.2021.01.030

26. Becker MAJ, Pronk AJM, Gecse K, et al. "Long-term outcomes of 'temporary' defunctioning in patients with severe perianal Crohn's disease." Colorectal Dis. 2025;27(2):e17289. doi:10.1111/codi.17289

27. Rosen DR, Brown ME, Cologne KG, Ault GT, Strumwasser AM. "Long-term follow-up of Fournier's gangrene in a tertiary care center." J Surg Res. 2016;206(1):175–181. doi:10.1016/j.jss.2016.06.091

28. Hajibandeh S, Hajibandeh S, Maw A. "Purse-string skin closure versus linear skin closure in people undergoing stoma reversal." Cochrane Database Syst Rev. 2024;3:CD014763. doi:10.1002/14651858.CD014763.pub2