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ORIGINAL ARTICLE
Year : 2000  |  Volume : 17  |  Issue : 1  |  Page : 16-19
 

Martius procedure revisited for urethrovaginal fistula


Department of Urology, Topiwala National Medical College & B. Y Nair Charitable Hospital, Mumbai, India

Correspondence Address:
N P Rangnekar
5, Radha Bhuvan, 176, L. J. Road. Shivaji Park, Dadar, Mumbai - 400 028
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Background: Urethrovaginal fistula is a dreadful com­plication of obstetric trauma due to prolonged labour or obstetric intervention commonly seen in developing coun­tries. Due to prolonged ischaemic changes, the fistula is resistant to healing. The strategic location of the fistula leads to postoperative impairment of continence mecha­nism. Anatomical repair was previously the commonest mode of surgical management, but was associated with a miserable cumulative cure rate ranging from 16-60%. Hence we tried to study the efficacy of Martius procedure in the management of urethrovaginal fistula.
Material and Methods: We studied the outcome of 12 urethrovaginal fistulae, all caused by obstetric trauma, treated surgically with Martius procedure in 8 and with anatomical repair in 4, retrospectively. 9 patients had re­current fistulae while I patient had multiple fistulae. Pa­tients were followed up for the period ranging from 6 months to 4'/2 years for fistula healing, continence and postoperative complications like dvspareunia.
Results: Cumulative cure rate ofMartius procedure was 87.5% with no postoperative stress incontinence, while fistula healing rate of anatomical repair was only 25% (I patient out of 4) which was also complicated by Intrin­sic Sphincter Deficiency (ISD). In case of recurrent fistu­lae the success rate of anatomical repair was 0% compared to 83.33% with Martius procedure.
Conclusions: Martius procedure has shown much bet­ter overall cure rate compared to anatomical repair be­cause - a) it provides better reinforcement to urethral suture line, b) it provides better blood supply and lymph drainage to the ischaemic fistulous area, c) provides sur­face for epithelialization and, d) helps to maintain conti­nence. Hence we recommend Martius procedure as a surgical modality for the treatment of urethrovaginal fis­tula.


Keywords: Martius Procedure; Urethrovaginal Fistula


How to cite this article:
Rangnekar N P, Ali N I, Patil B S, Pathak H R. Martius procedure revisited for urethrovaginal fistula. Indian J Urol 2000;17:16-9

How to cite this URL:
Rangnekar N P, Ali N I, Patil B S, Pathak H R. Martius procedure revisited for urethrovaginal fistula. Indian J Urol [serial online] 2000 [cited 2019 May 22];17:16-9. Available from: http://www.indianjurol.com/text.asp?2000/17/1/16/41006



   Introduction Top


Urethrovaginal fistula is an uncommon condition in the developed countries, usually related to urethrovaginal in­juries. In developing countries like India, it is one of the common, dreadful complications of obstetric trauma due to prolonged labour or obstetric intervention. [1],[2] Other causes of urethrovaginal fistula are operative procedures of vagina and urethra (like urethral diverticulectomy or anterior vaginal repair), pelvic fracture injuries, vaginal / urethral neoplasm especially after treatmet with radiation and radical surgeries like Wertheim's hysterectomy. [3],[4],[5] Symptoms of the urethrovaginal fistula depend on the lo­cation of the fistula in relation to sphincteric mechanism. Proximal urethral fistulae involving bladder neck may re­sult in continuous or stress incontinence while distal fis­tulae may lead to messy voiding through vagina without true incontinence. Hence the problem is twofold: 1) to create a neourethra and, 2) to maintain urinary continence.

Over the years many surgical procedures have been described for the treatment of urethrovaginal fistulae with varying success. These include urethral marsupialization, [6] vaginal flap closure, [2] labial fat pad repair (Martius proce­dure), [7],[8],[9] full thickness skin graft reconstruction, [10] mus­culo-cutaneous flap interposition [11] and bladder-flap technique. [12] Anatomical vaginal flap closure is one of the commonest procedures undertaken but with a miserable cumulative cure rate ranging from 16% without associ­ated anti-incontinence procedure to 60% with anti-incon­tinence procedure. Of the 46 patients with urinary vaginal fistulae seen in the department of Urology in our institu­tion over 4 years (1995-1999) 12 had urethrovaginal fis­tulae. We tried to study efficacy of Martius procedure as a surgical treatment of urethrovaginal fistula in comparison with anatomical vaginal flap repair with a follow-up rang­ing from 6 months to 4½ years.[Table 1]


   Material and Methods Top


12 women with urethrovaginal fistulae aged between 22 and 45 years were studied retrospectively. The etiology of fistulae in all 12 cases was obstetric trauma. Fistulae varied in size from 2 mm to 8 mm. All the patients had fistula located in proximal urethra involving bladder neck.

Preoperative evaluation: Identification of urinary vagi­nal fistula was based on typical history, per Speculum ex­amination of the vagina, intravenous urography and cystourethroscopy. [3],[4],[11],[13],[14] 2 patients who had very small fistulae (2 mm each in diameter) were detected with the help of intravesical methylene blue instillation/vaginal tampon test. [11],[13],[15],[16]

Out of 12 patients with urethrovaginal fistulae, 3 pa­tients presented for primary treatment while 9 patients had recurrent fistulae. Out of 12 patients, 8 underwent Martius­flap repair, while 4 underwent anatomical vaginal flap clo­sure of the fistula. Only 1 patient had multiple (2) fistulae. Out of 9 patients with recurrent fistulae, 3 patients had undergone anatomical repair while one fistula was prima­rily treated with anatomical repair.

Martius procedure combines freshening of the edges of fistula after raising a U-shaped vaginal flap. Fistula was sutured in two layers with urethral wall approximation and Lambert's sutures of the periurethral tissue over it. This suture line was reinforced by interposition of mobilized, well-vascularized fat pad from labia majora. A 10-cm-long pedicle can be raised on the blood supply from the branches of the pudendal artery. The fat pad is then tunneled be­neath labia minora into the vaginal lumen, where it is su­tured in place to the bladder or urethral wall. Final layer of closure was anterior vaginal wall flap. There is no cos­metic deformity in the perineum. [7],[8],[9],[11] The bladder is drained with suprapubic as well as per uretheral catheter for at least 3 weeks. No sexual intercourse was allowed for at least 3 months postoperatively.

Anatomical vaginal flap repair was carried out by de­veloping a plane between vagina and bladder/urethra fa­cilitated by saline-adrenaline instillation, raising U-shaped vaginal flap. Fistulous tract was not excised but the edges were freshened to decrease iatrogenic increase in the fistula diameter. Freshened edges of the fistula were closed in two layers with suture lines perpendicular to each other and finally closing vaginal wall flap over the repair. [4],[14],[17] Postoperatively the bladder was drained with suprapubic as well as per urethral catheter for a minimum of 3 weeks with avoidance of sexual intercourse for 3 months. After 3 weeks postoperatively per urethral catheter was removed and suprapubic catheter was clamped to give a voiding trial. [2] Failure of the fistula repair was diagnosed by con­tinuous vaginal leak confirmed on per Speculum examina­tion after instillation of methylene blue through suprapubic catheter. Postoperative incontinence without recurrence of the fistula was diagnosed on urodynamic study carried out on Dantec-5500 machine. [18]


   Results Top


8 patients out of 12 were offered Martius-flap repair while 4 patients were treated with anatomical vaginal flap closure. Only 1 out of 8 patients undergoing Martius flap had recurrence with success rate of 87.5% compared to 3 failures out of 4 (success rate of 25%) with anatomical vaginal flap repair. (See table)

All the 3 recurrent fistulae treated with anatomical re­pair had failure of surgical procedure compared to only I out of 6 recurrent fistulae treated with Martius flap. None of the fistulae primarily treated with Martius flap had re­currence. The only patient who had complete healing of fistula with anatomical repair developed stress inconti­nence compared to none of the patients undergoing Martius procedure. This was confirmed with urodynamic study showing a low abdominal leak-point pressure of 54 cm of water suggestive of intrinsic sphincter deficiency (ISD). [18] This patient was offered pubo-vaginal sling procedure but the patient has defaulted.

With respect to postoperative complications Martius­flap repair caused no incontinence or dyspareunia com­pared to the only patient cured with anatomical repair that suffered from both of these complications. With respect to the timing of surgery after initial injury or surgery de­finitive procedure was carried out within 79 to 192 days with a mean of 102 days. Out of 11 patients who were treated after 3 months of previous intervention 8 fistulae healed while 3 had recurrence showing success rate of 72.73%. With respect to the time taken for surgical proce­dure, mean time taken for Martius-flap was only 20 min­utes more than anatomical repair. Both types of procedures could be finished well within spinal anaesthesia time us­ing Bupivacaine.


   Discussion Top


Different methods of fistula closure have varying suc­cess rate ranging from 16% to 50% with vaginal flap re­pair to 64% using posterior bladder flap. Those anatomical vaginal flap repairs, which were combined with anti-in­continence procedure, showed increased cumulative cure rate (without stress incontinence) to 60%. Anatomical vaginal flap repair in our study showed fistula healing rate of 25%, but the cumulative cure rate was 0% as the only healed fistula patient developed postoperative ISD. This miserable healing rate can probably be accounted by is­chaemia caused by continuous pressure by the foetal head during prolonged labour.

Our study showed 87.5% cumulative cure rate which was comparable to 94% to 100% cure rates showed by Symmonds et al and Birkhoff et al respectively. Martius procedure works better by reinforcing the fistulous suture line. It provides additional blood supply and lymph drain­age for the fistulous area as well as surface for epitheliali­zation. Hence it should be preferred more so in case of recurrent urethrovaginal fistulae whose edges are much more fibrotic and ischaemic and resists healing. Martius procedure prevents overlapping of urethral and vaginal suture lines and also facilitates re-establishment of conti­nence. Moreover it is a transvaginal procedure, which can be done under regional anaesthesia and does not require great surgical expertise. Hence we recommend Martius procedure for the treatment of urethrovaginal fistula.

The only urethrovaginal fistula that had recurrence af­ter Martius-flap repair in our study probably was due to early intervention, i.e. within 3 months (79 days after fail­ure of earlier surgery). The timing of surgery is important due to its effect on local tissues, which helps to reduce tissue oedema and inflammation. [2],[11] Hence we recommend a period of 3 months between injury or prior intervention and definitive surgical procedure.


   Acknowledgement Top


We sincerely thank Dr. Shriram S. Joshi, Consultant Urologist at Jaslok Hospital and Research Center, for edi­torial assistance.[22]

 
   References Top

1.Hamlin RHJ, Nicolson EC. Reconstruction of urethra totally de­stroyed in labour. Br Med J 1969; 1: 147.  Back to cited text no. 1    
2.Gerber GS, Schoenberg HW. Female urinary tract fistulas. J Urol 1993; 149: 229-236.  Back to cited text no. 2  [PUBMED]  
3.Wein AJ, Malloy TR, Carpiniello VL, Greenberg SH, Murphy JJ. Repair of vesicovaginal fistula by a suprapubic, transvesical ap­proach. Surg Gynecol Obstet 1980; 150: 57.  Back to cited text no. 3  [PUBMED]  
4.Goodwin WE, Scardino PT. Vesicovaginal and ureterovaginal fis­tula: A summary of 25 years of experience. J Urol 1980; 123: 370.  Back to cited text no. 4  [PUBMED]  
5.Wein AJ. Vesicovaginal fistula. In: Current therapy in genitourinary surgery. Resnick MI, Kursh E (eds.). Philadelphia, B. C. Decker 1987;209-213.  Back to cited text no. 5    
6.Lamensdorf H, Campere DE, Begley GF. Simple surgical correc­tion of urethrovaginal fistula. Urol 1977; 10: 152.  Back to cited text no. 6    
7.Martius H. Die operative wiederherstellung der vollkommen fehlenden hamrohre and des schiessmuskels derselben. Zentralbl Gynako1 1928; 52:480.  Back to cited text no. 7    
8.Wang YU, Hadley HR. The use of rotated, vascularized pedicle flaps for complex transvaginal procedures. J Urol 1993; 149: 590­-592.  Back to cited text no. 8    
9.Leach GE. Urethrovaginal fistula repair with Martius labial fat pad graft. Urol Clin North Am 1991; 18: 409-413.  Back to cited text no. 9  [PUBMED]  
10.McKinney DE. Use of full thickness patch graft in urethrovaginal fistula. J Urol 1979; 122: 416.  Back to cited text no. 10  [PUBMED]  
11.Patil U, Waterhouse K, Laungani G. Management of 18 difficult vesicovaginal and urethrovaginal fistulas with modified Ingelman­Sundberg and Martius operations. J Urol 1980; 123: 653-656.  Back to cited text no. 11  [PUBMED]  
12.Tanagho EA. Bladder neck reconstruction for total urinary inconti­nence. 10 years of experience. J Urol 1981; 125: 321-326.  Back to cited text no. 12    
13.O'Conor VJ. Review of experience with vesicovaginal fistula re­pair. J Urol 1980; 123: 367.  Back to cited text no. 13    
14.Keettel WC, Schring FG, de Prosse CA, Scott JR. Surgical ma­nagement of urethrovaginal and vesicovaginal fistulas. Am J Obstet Gynaecol 1978: 131: 425-431.  Back to cited text no. 14    
15.O'Conor VJ, Sokol JK, Bulkley GJ, Nanninga JD. Suprapubic clo­sure of vesicovaginal fistula. J Urol 1973; 109: 51-54.  Back to cited text no. 15    
16.Moir JC. Vesicovaginal fistula as seen in Britain. J Obst Gynaecol Brit Commonw 1973; 80: 598.  Back to cited text no. 16    
17.Barnes R, Hadley H, Johnston O. Transvaginal repair of vesico­vaginal fistulas. Urology 1977; 10: 258.  Back to cited text no. 17    
18.McGuire EJ. Urodynamic evaluation of stress incontinence. Urol Clin North Am 1995: 22: 551-555.  Back to cited text no. 18    
19.Birkhoff JD, Wechsler M, Romas NA. Urinary fistulas: vaginal re­pair using a labial fat pad. J Urol 1977: 117: 595-597.  Back to cited text no. 19    
20.Symmonds RE, Hill LM. Loss of urethra: a report of 50 patients. Am J Obstet Gynaecol 1978; 130: 130.  Back to cited text no. 20    
21.Blaivas JG. Vaginal flap urethral reconstruction: an alternative to the bladder flap neourethra. J Urol 1989; 141: 542.  Back to cited text no. 21  [PUBMED]  
22.Ellis LR, Hodges CV. Experience with female urethral reconstruc­tion. J Urol 1969;102:214.  Back to cited text no. 22  [PUBMED]  



 
 
    Tables

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    Abstract
    Introduction
    Material and Methods
    Results
    Discussion
    Acknowledgement
    References
    Article Tables

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