Year : 2000 | Volume
: 17 | Issue : 1 | Page : 16--19
Martius procedure revisited for urethrovaginal fistula
NP Rangnekar, N Imdad Ali, BS Patil, HR Pathak
Department of Urology, Topiwala National Medical College & B. Y Nair Charitable Hospital, Mumbai, India
N P Rangnekar
5, Radha Bhuvan, 176, L. J. Road. Shivaji Park, Dadar, Mumbai - 400 028
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«SQ»/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.
|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;17:16-19
|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 2020 Sep 25 ];17:16-19
Available from: http://www.indianjurol.com/text.asp?2000/17/1/16/41006
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. , 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. ,, 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,  vaginal flap closure,  labial fat pad repair (Martius procedure), ,, full thickness skin graft reconstruction,  musculo-cutaneous flap interposition  and bladder-flap technique.  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
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. ,,,, 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. ,,,
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. ,,, 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. ,, 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.  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. 
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).  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.
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. , Hence we recommend a period of 3 months between injury or prior intervention and definitive surgical procedure.
We sincerely thank Dr. Shriram S. Joshi, Consultant Urologist at Jaslok Hospital and Research Center, for editorial assistance.
|1||Hamlin RHJ, Nicolson EC. Reconstruction of urethra totally destroyed in labour. Br Med J 1969; 1: 147.|
|2||Gerber GS, Schoenberg HW. Female urinary tract fistulas. J Urol 1993; 149: 229-236.|
|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.|
|4||Goodwin WE, Scardino PT. Vesicovaginal and ureterovaginal fistula: A summary of 25 years of experience. J Urol 1980; 123: 370.|
|5||Wein AJ. Vesicovaginal fistula. In: Current therapy in genitourinary surgery. Resnick MI, Kursh E (eds.). Philadelphia, B. C. Decker 1987;209-213.|
|6||Lamensdorf H, Campere DE, Begley GF. Simple surgical correction of urethrovaginal fistula. Urol 1977; 10: 152.|
|7||Martius H. Die operative wiederherstellung der vollkommen fehlenden hamrohre and des schiessmuskels derselben. Zentralbl Gynako1 1928; 52:480.|
|8||Wang YU, Hadley HR. The use of rotated, vascularized pedicle flaps for complex transvaginal procedures. J Urol 1993; 149: 590-592.|
|9||Leach GE. Urethrovaginal fistula repair with Martius labial fat pad graft. Urol Clin North Am 1991; 18: 409-413.|
|10||McKinney DE. Use of full thickness patch graft in urethrovaginal fistula. J Urol 1979; 122: 416.|
|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.|
|12||Tanagho EA. Bladder neck reconstruction for total urinary incontinence. 10 years of experience. J Urol 1981; 125: 321-326.|
|13||O'Conor VJ. Review of experience with vesicovaginal fistula repair. J Urol 1980; 123: 367.|
|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.|
|15||O'Conor VJ, Sokol JK, Bulkley GJ, Nanninga JD. Suprapubic closure of vesicovaginal fistula. J Urol 1973; 109: 51-54.|
|16||Moir JC. Vesicovaginal fistula as seen in Britain. J Obst Gynaecol Brit Commonw 1973; 80: 598.|
|17||Barnes R, Hadley H, Johnston O. Transvaginal repair of vesicovaginal fistulas. Urology 1977; 10: 258.|
|18||McGuire EJ. Urodynamic evaluation of stress incontinence. Urol Clin North Am 1995: 22: 551-555.|
|19||Birkhoff JD, Wechsler M, Romas NA. Urinary fistulas: vaginal repair using a labial fat pad. J Urol 1977: 117: 595-597.|
|20||Symmonds RE, Hill LM. Loss of urethra: a report of 50 patients. Am J Obstet Gynaecol 1978; 130: 130.|
|21||Blaivas JG. Vaginal flap urethral reconstruction: an alternative to the bladder flap neourethra. J Urol 1989; 141: 542.|
|22||Ellis LR, Hodges CV. Experience with female urethral reconstruction. J Urol 1969;102:214.|