Introduction/Background Rectovaginal and vesico-urethrovaginal fistulas after gynecologic surgical procedures are a major concern and represent a challenge for surgeons.
Some decades ago H Martius described an interpositional tissue flap using the bulbocavernosus muscle with fibroadipose tissue from the labia majora for urethrovaginal fistula repair. Subsequently, the technique has been modified developing a less invasive technique.
Methodology For a proper technique, the patient is placed in a modified lithotomy position and a temporary transurethral urinary catheter is placed during the surgery. The procedure starts with direct primary anatomical repair: after the identification of the fistulous tract, a Foley catheter is placed through it, this maneuver allows a gentle traction of the fistula. Then, a circumferential incision around the fistula is made in order to separate and mobilize bladder and vaginal walls. Anterior and posterior vaginal wall flaps are developed in healthy tissue using sharp dissection to expose the perivesical fascia. Once the bladder wall is mobilized the defect is closed by suturing.
Results A lateral incision on the labia majora to expose the fatty pad is performed. There is a natural tissue plane around the pad for the dissection, it´s important to ensure that the blood supply is maintained. Once posterior dissection is performed, vascularized labial fatty flap is mobilized and transposed into the vagina by a clamp under the vaginal wall, for covering the fistula repair site without tension. Care should be taken to stay lateral to the bulbocavernosus and ischiocavernosus muscles in order to prevent significant bleeding or scar deformity. Flap must be fixed with absorbable suture. Finally, the skin and vaginal incisions are closed with an absorbable synthetic suture.
Conclusion In general, the Martius technique and its modifications are used for the repair of complex fistulas in the perineal region, either urogynecological or rectovaginal including recurrent, radiation induced or large fistulas
Disclosure Nothing to disclose
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.