Would LIFT Have Prevented These Complications?
No, LIFT would not have prevented postoperative anorgasmia, but it would have dramatically reduced the risk of sphincter weakness and incontinence compared to fistulotomy. The anorgasmia is likely unrelated to the surgical technique choice, while the sphincter dysfunction directly results from dividing sphincter muscle during fistulotomy—a complication LIFT specifically avoids. 1, 2
Why LIFT Preserves Sphincter Function
LIFT achieves incontinence rates of only 1.6% compared to 7.8% with other techniques, and 53% of patients actually experience improved continence postoperatively. 1, 2 This dramatic difference occurs because LIFT ligates the fistula tract in the intersphincteric space without dividing any sphincter muscle, whereas fistulotomy requires cutting through sphincter fibers. 3, 4
The Critical Distinction
Fistulotomy divides the external anal sphincter even in "low" transsphincteric fistulas, creating permanent sphincter defects that manifest as weakness and potential incontinence, particularly problematic in women with anterior fistulas and patients with pre-existing sphincter compromise 3, 4
LIFT preserves all sphincter muscle by accessing the tract through the intersphincteric groove, ligating it at both ends, and removing the diseased tissue without cutting functional muscle 1, 3
No patient in multiple studies developed new incontinence after LIFT, with some experiencing improvement in baseline continence scores 2, 4, 5
The Anorgasmia Question
The anorgasmia you experienced is not a recognized complication of either fistulotomy or LIFT procedures in the medical literature. 6, 1, 7 This suggests:
The sexual dysfunction likely stems from factors unrelated to the specific surgical technique chosen (nerve injury, psychological trauma, medication effects, or underlying disease process)
LIFT would not have prevented this complication since it doesn't address whatever mechanism caused the anorgasmia 1, 7
LIFT Success Rates and Limitations
While LIFT would have protected your sphincter function, you should understand its healing profile:
Overall healing rates range from 69-77% in cryptoglandular fistulas with median follow-up over 1 year 1, 8
Recurrence occurs in approximately 18-20% of patients, with median time to failure around 4 months when it occurs 1, 8, 9
Critical success factors include: single non-branching tracts, absence of active proctitis, and non-smoking status (smoking increases failure risk 3.2-fold) 1, 2
When LIFT Fails
The crucial advantage: LIFT failure does not worsen continence. 2 When recurrence occurs:
The fistula typically converts from transsphincteric to intersphincteric (simpler anatomy) 3
Subsequent fistulotomy can then be performed with preservation of the external sphincter 3
You maintain sphincter integrity even if the initial LIFT fails 2, 3
The Clinical Algorithm That Should Have Been Followed
For a low transsphincteric fistula, the decision tree should prioritize sphincter preservation:
Step 1: Assess Sphincter Risk Factors
- Female with anterior fistula: LIFT strongly preferred over fistulotomy 7, 3
- Any baseline continence issues: LIFT mandatory 3, 4
- Prior sphincter surgery: LIFT mandatory 1, 7
Step 2: Rule Out Contraindications to Definitive Surgery
- Perform proctosigmoidoscopy to exclude active proctitis (absolute contraindication to both procedures) 6, 7
- Obtain pelvic MRI to confirm single, non-branching tract anatomy 6, 7
Step 3: Choose Procedure
- If uncomplicated low fistula with NO risk factors: Either fistulotomy or LIFT acceptable, though LIFT still safer for continence 7, 3
- If ANY sphincter risk factors present: LIFT is the appropriate choice 1, 3, 4
Critical Pitfall in Your Case
The fundamental error was performing fistulotomy without adequate assessment of sphincter risk. 7, 3 The European Society of Coloproctology explicitly states that division of even the lower third of the external sphincter carries "not insignificant" incontinence risk, especially in high-risk patients. 3
What Modern Guidelines Recommend
"Division of the lower part of the external anal sphincter is no longer necessary in the treatment of low transsphincteric fistulae" given LIFT's availability 3
LIFT should be considered first-line for low transsphincteric fistulas in patients where sphincter preservation is paramount 1, 3, 4
Fistulotomy remains acceptable only in carefully selected patients with truly uncomplicated anatomy and no continence concerns 7
Bottom Line
Your sphincter weakness was preventable with LIFT, but your anorgasmia would likely have occurred regardless of technique. 1, 2 The sphincter dysfunction represents a known, predictable consequence of dividing sphincter muscle during fistulotomy—precisely what LIFT was designed to avoid. 3, 4 The sexual dysfunction requires separate investigation as it's not attributable to either surgical approach. 6, 1, 7