Article

How I Do It: Martius Flap for Rectovaginal Fistulas

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Abstract

Rectovaginal fistulas present a difficult problem that is frustrating for patients and surgeons alike. Surgical options range from collagen plugs and endorectal advancement flaps to sphincter repairs or resection with coloanal reconstruction. For recurrent or complex rectovaginal fistulas, especially in the setting of prior radiation, Crohn's disease, or large wounds, bringing in healthy tissue into the space provides an excellent opportunity for improved results. The bulbocavernosus muscle and its surrounding vascularized tissue pedicle, first described by Martius in 1928, is an excellent option for fistula closure. Surgeons caring for these patients should be aware of this technique and have it as one method in their operative armamentarium when faced with these challenging cases.

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... Ma ona liczne grono zwolenników, a wyniki wczesne publikowane przez autorów są bardzo obiecujące (od 60% do 94% skuteczności). Niestety, odsetek nawrotów jest dość wysokinawet około 50% (28,29) . Kolejna technika to stosowanie plastyki z użyciem mięśnia smukłego uda na zachowanej szypule naczyniowo-nerwowej, co oprócz wypełnienia ubytku tkankowego pozwala na osiągnięcie lepszych wyników czynnościowych związanych 3 months after the surgery. ...
... The procedure has a lot of supporters, and the early outcomes published by different authors are very promising (60% up to 94% efficacy). Unfortunately, the rate of recurrence is relatively high -up to about 50% (28,29) . Another technique involves the use of plasty using the gracilis muscle on a preserved vascular-nervous pedicle, which not only replaces the lost tissue but also allows for better functional outcomes associated with additional muscle structure supplementing the loops of the external anal sphincter. ...
Article
A pathological communication between the rectum and the vagina, referred to as rectovaginal fistula, can develop as a result of a number of factors. Fistula caused by ionizing energy treatment, which belongs to the most serious late radiation-induced complications, is a special type of this abnormality. This type of fistulas are classified as complex fistulas. Their surgical treatment is very difficult and shows poor efficacy as well as high rate of recurrence. Therefore, it is still a serious and current problem of women after radiation therapy for gynecologic cancer. The quality of life in patients with this complication is dramatically poor. Despite completed cancer treatment, women with radiation-induced rectovaginal fistula are often unable to resume their previous social roles, including work. Therefore, it is important to determine the optimal management strategy in these patients. Although it may seem impossible to develop a simple diagnostic and therapeutic algorithm due to different fistula locations and sizes, the knowledge on the basic management strategies increases the chance of success. A surgery using the transabdominal approach described by Parks is the primary surgical technique. However, new reports on repair techniques, particularly less invasive ones, occasionally occur in literature. Therefore, we present a current literature review of treatment options in radiation-induced rectovaginal fistulas. © Curr Gynecol Oncol 2016.
... Kniery etal. 2015 reported that Martius flap is very effective method in treating rectovaginal fistula [12]. In the present study, all cases of rectovaginal fistula showed complete healing without recurrence in patient operated by Martius flap and one patient only showed recurrence in patients group not using Martius flap (9.1%), but this result is not statistically significant and may be attributed to the small size of patient sample. ...
Article
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Introduction: A rectovaginal fistula (RVF) is an epithelium-lined abnormal tract between the rectum and the vagina .It is often a challenging problem for both the patients and to the surgeons. In literature, there is still debate regarding the best treatment options for rectovaginal fistulas. To assess the results of the treatment of rectovaginal fistulas with incontinence and impaired anal tonus using fistulectomy, sphincteroplasty with or without bulbocavernosus muscle (Martius) flap. Patients and Methods: A total of 22 consecutive patients with simple RVFs were included and assigned to transperineal repair. The patients were divided into two groups, group1: with Martius flap; group2: without Martius flap .Postoperatively, patients were followed up for one year. Results: All of the simple rectovaginal fistula cases are best treated with fistulectomy, sphincteroplasty. Martius flap has no effect in prevention of fistula recurrence with no statistically significant difference between group using Martius flap and group not using Martius flap. Conclusion: Repair of rectovaginal fistula with fistulectomy, sphincteroplasty without diversion is ideal for treatment of simple rectovaginal fistula. Treating the fistula without Martius flap does not affect outcome and may be treated without.
... medical history of patients37 non oncologic context: anorectal malformation with rectovaginal fistula *ACA : colo-anal anastomosis ...
Article
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Introduction Rectovaginal fistula (RVF) is defined as an abnormal communication between the anterior wall of the rectum and the posterior wall of the vagina. Many surgical techniques have been described in the treatment of RVF. However, none has proved its superiority. The aim of the study was to evaluate the functional results of surgical treatment of RVF using Martius and Falandry techniques in order to assess the feasibility and the efficacy of these techniques which were first described for vesico-vaginal fistulas. Methods The study was a retrospective case series conducted in a single centre: Department of general surgery at Ibn Sina University Hospital in Rabat. We included patients with rectovaginal fistula consecutively recruited from 2011 to 2014. 10 patients developed RVF after surgery for rectal cancer (9 cases), uterine cancer (1 case). One patient had RVF for ano-rectal malformation. Colostomy was performed before the treatment of fistula in 9 cases (82%). They underwent surgical treatment using Falandry (8 patients) and Martius techniques (3 patients) performed by an experienced urologist surgeon. Results No postoperative complications were recorded. Time to discharge was postoperative day 3-4. There was a complete disappearance of RVF in 8 patients (72.7% of cases), relapse in 2 cases (18%), and failure in one case (9%). The average follow-up was 12.6 +/-10 months. Functionally, no long-term cases of fecal incontinence or dyspareunia were noted. Conclusion The choice of surgical technique in the treatment of RVF remains difficult because of poor literature data and absence of consensus. RVF repair results either by Martius or Falandry techniques are encouraging with low morbidity.
... The interposition of healthy, well-vascularized tissue, such as the bulbocarvernous muscle [25,26] with its surrounding fibroadipose component that protects the direct repair and separates the rectal and vaginal walls, may be a good option in these particularly difficult cases. ...
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Background Rectovaginal fistulas represent 5% of all anorectal fistulae and are a disastrous manifestation of Crohn’s disease that negatively affects patients’ social and sexual quality of life. Treatment remains challenging for colorectal surgeons, and the recurrence rate remains high despite the numerous available options. Case presentationWe describe a 31-year-old female patient with a Crohn’s disease-related recurrent perineo-vaginal and recto-vaginal fistulae and a concomitant mullerian anomaly. She complained of severe dyspareunia associated with penetration difficulties. The patient’s medical history was also significant for a previous abdominal laparoscopic surgery for endometriosis for the removal of macroscopic nodules and a septate uterus with cervical duplication and a longitudinal vaginal septum. The patient was successfully treated using a Martius’ flap. The postoperative outcome was uneventful, and no recurrence of the fistula occurred at the last follow-up, eight months from the closure of the ileostomy. Conclusion Martius’ flap was first described in 1928, and it is considered a good option in cases of rectovaginal fistulas in patients with Crohn’s disease.The patient should be referred to a colorectal centre with expertise in this disease to increase the surgical success rate.
... Many methods of repair have been described, including various rotational tissue and endorectal advancement flap closures. [47][48][49][50][51] When tissues are not ideal for local repair, a transabdominal approach with mobilization of the rectum below the level of the fistula, resection of diseased bowel, and anastomosis using healthy proximal colon may be the only option. Interposition of normal tissue such as omentum between connecting organs is recommended, and a covering stoma should always be employed. ...
Article
Radiotherapy not only plays a pivotal role in the cancer care pathways of many patients with pelvic malignancies, but can also lead to significant injury of normal tissue in the radiation field (pelvic radiation disease) that is sometimes as challenging to treat as the neoplasms themselves. Acute symptoms are usually self-limited and respond to medical therapy. Chronic symptoms often require operative intervention that is made hazardous by hostile surgical planes and unforgiving tissues. Management of these challenging patients is best guided by the utmost caution and humility.
Chapter
The most common cause of rectovaginal fistula is birth injury although anorectal surgeries performed in women can cause rectovaginal fistula. In the case of fistula not identified by physical examination, contrast medium should be used to check for fistula tract in the high rectovaginal fistula. Successful treatment of rectovaginal fistula depends greatly on the cause, especially when developed from Crohn’s disease or radiation injury, the prognosis is poor. To increase success rate, surgical method should be selected depending on the RVF location, cause, degree of infection on the surrounding tissue, history of treatment, and sphincter function. Transanal, transvaginal, and transperineal approaches are main surgical options for rectovaginal fistula.
Chapter
Rectovaginal fistula is an abnormal communication between the rectum and vagina that results after traumatic, infectious, neoplastic, and inflammatory insult to the rectovaginal septum. This distressing condition afflicts millions of women worldwide, causing the passage of gas and/or feces through the vagina. This chapter reviews the etiology, classification, and diagnosis of rectovaginal fistula. Medical and surgical treatment should be tailored to each particular patient since there is great heterogeneity in the cohort of women suffering from the condition.
Chapter
Despite advances in surgical techniques, rectovaginal fistulas (RVF) remain a challenging surgical problem.
Chapter
Rectovaginal fistulas (RVFs) are an abnormal communication between the anorectum and vagina that can be disabling for patients and challenging to treating surgeons. Addressed in this chapter are RVFs resulting from obstetric trauma, cryptoglandular disease, and Crohn’s disease. A number of different surgical approaches have been described in the treatment of rectovaginal fistulas. A single “best” approach has not been identified, and surgeons must be familiar with a variety of techniques in order to determine which approach is best suited for their patient. This chapter will review the most commonly described techniques and propose an algorithm for managing these complex patients.
Re-operative surgery for genitourinary fistulas to the colorectum is very distressing condition for the patients. These fistulas are extremely complex and at times may require a staged, multidisciplinary approach in order to correct them. Post-operative and recurrent genitourinary fistula to the colorectum can occur as a consequence of pelvic disorders, including trauma, iatrogenic injury, inflammatory bowel disease, pelvic neoplasm, and infection. Basic surgical principles, such as gentle handling of the tissues, curetting of the fistula tract, adequate debridement of unhealthy tissue, and adequate mobilization of tissue to allow tension-free tissue approximation, are essential for a successful outcome. Surgical therapy for these fistulas remains largely based on the surgeons' preference and is influenced by many retrospective reports. Currently, there is no specific treatment algorithm available for these post-operative and recurrent genitourinary fistulas to the colorectum. Through this article, we will highlight the various treatment options available and have attempted to formulate a treatment algorithm for post-operative and recurrent rectourethral, rectovaginal, and ileal pouch vaginal fistulas.
Article
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Background: Rectovaginal fistulas are rare, and the majority is of traumatic origin. The most common causes are obstetric trauma, local infection, and rectal surgery. This guideline does not cover rectovaginal fistulas that are caused by chronic inflammatory bowel disease. Methods: A systematic review of the literature was undertaken. Results: Rectovaginal fistula is diagnosed on the basis of the patient history and the clinical examination. Other pathologies should be ruled out by endoscopy, endosonography or tomography. The assessment of sphincter function is valuable for surgical planning (potential simultaneous sphincter reconstruction). Persistent rectovaginal fistulas generally require surgical treatment. Various surgical procedures have been described. The most common procedure involves a transrectal approach with endorectal suture. The transperineal approach is primarily used in case of simultaneous sphincter reconstruction. In recurrent fistulas. Closure can be achieved by the interposition of autologous tissue (Martius flap, gracilis muscle) or biologically degradable materials. In higher fistulas, abdominal approaches are used as well. Stoma creation is more frequently required in rectovaginal fistulas than in anal fistulas. The decision regarding stoma creation should be primarily based on the extent of the local defect and the resulting burden on the patient. Conclusion: In this clinical S3-Guideline, instructions for diagnosis and treatment of rectovaginal fistulas are described for the first time in Germany. Given the low evidence level, this guideline is to be considered of descriptive character only. Recommendations for diagnostics and treatment are primarily based the clinical experience of the guideline group and cannot be fully supported by the literature.
Article
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The incidence of anal abscess is relatively high, and the condition is most common in young men. A systematic review of the literature was undertaken. This abscess usually originates in the proctodeal glands of the intersphincteric space. A distinction is made between subanodermal, intersphincteric, ischioanal, and supralevator abscesses. The patient history and clinical examination are diagnostically sufficient to establish the indication for surgery. Further examinations (endosonography, MRI) should be considered in recurrent abscesses or supralevator abscesses. The timing of the surgical intervention is primarily determined by the patient's symptoms, and acute abscess is generally an indication for emergency treatment. Anal abscesses are treated surgically. The type of access (transrectal or perianal) depends on the abscess location. The goal of surgery is thorough drainage of the focus of infection while preserving the sphincter muscles. The wound should be rinsed regularly (using tap water). The use of local antiseptics is associated with a risk of cytotoxicity. Antibiotic treatment is only necessary in exceptional cases. Intraoperative fistula exploration should be conducted with extreme care if at all; no requirement to detect fistula should be imposed. The risk of abscess recurrence or secondary fistula formation is low overall, but they can result from insufficient drainage. Primary fistulotomy should only be performed in case of superficial fistulas and by experienced surgeons. In case of unclear findings or high fistulas, repair should take place in a second procedure. In this clinical S3 guideline, instructions for diagnosis and treatment of anal abscess are described for the first time in Germany.
Article
Background: Treatment of rectovaginal fistulas is difficult, and many surgical interventions have been developed. The best surgical intervention for the closure of these fistulas is still unclear. Objective: A systematic review was performed reporting the outcomes of different surgical techniques for rectovaginal fistulas. Data sources: Medline (PubMed, Ovid), Embase (Ovid), and The Cochrane Library databases were searched for eligible articles as well as the references of these articles. Study selection: Two independent reviewers analyzed the search results for eligible articles based on title, abstract, and described results. Intervention(s): Any surgical intervention for the closure of rectovaginal fistulas was included. Main outcome measures: The main outcome was closure rate. Secondary outcomes were quality of life, morbidity, and the effect on sexual functioning. Results: Many articles with different operative techniques were identified and classified in the following categories: advancement flaps (endorectal and endovaginal), transperineal closure, Martius procedure, gracilis muscle transposition, rectal resections, transabdominal closure, mesh repair, plugs, endoscopic repairs, closure with biomaterials, and miscellaneous techniques. Results vary widely with closure rates between 0% and >80%. None of the studies were randomized. Because of the poor quality of the identified studies, the comparison of results and performance of a meta-analysis were not possible.Data regarding the secondary outcomes were mostly unavailable. Limitations: The major limitation of this review was the limited availability of high-quality prospective studies, making it impossible to perform a meta-analysis. Conclusions: No conclusion about the best surgical intervention for rectovaginal fistulas could be formulated. More large studies of high quality are needed to find the best treatment for rectovaginal fistulas. A design for these high-quality studies was formulated.
Article
Radiation-induced fistulas of the vagina are rare, occurring in only 1 of 3% of patients treated for cancer of the uterine cervix. Primary surgical repair of these fistulas is usually unsuccessful because the defect is a result of devascularization. This type of radiation injury results from endarteritis obliterans, and successful repair requires an accessory blood supply. From 1971 to 1980, the authors performed 14 Martius procedures on 12 patients with radiation-induced rectovaginal fistulas. Eleven patients had successful closure of their fistulas using this procedure, and no operative complications occurred. The Martius procedure is effective for most radiation-induced vaginal fistulas, and the operation is well tolerated by most patients.
Article
Complex, rectovaginal fistula (RVF) are uncommon but difficult therapeutic problems. Local repair and flap advancement techniques have a high incidence of recurrence with poor functional outcomes. Transperineal repair with anal sphincter reconstruction, when indicated, and placement of a Martius flap (bulbocavernosus pedicled transplant) result in improved rates of repair and better functional outcomes. A consecutive series of patients were retrospectively reviewed from a prospective database between 2002 and 2006. Data were gathered from 2 colon- and rectal-specialty practices. Patient demographics and operative and functional outcomes were documented. Sixteen patients with a mean age of 39.5 years (17-62) were treated. Etiology of the fistula was obstetric (9), cryptoglandular (5), and Crohn's disease (2). They had undergone a mean of 1.5 (0-4) prior repairs, and 6 had a preexisting diverting stoma before repair. Preoperatively, anal sphincter disruption was identified in 11 patients, and fecal incontinence was identified in 5 patients all with anal sphincter disruption. Dyspareunia was identified in 1 of 13 sexually active patients preoperatively. At a mean follow-up of 75 weeks (24-190), 1 recurrent fistula was identified (6.2%). Stomas were reversed in all patients. Two patients complained of fecal incontinence postoperatively. Five patients had dyspareunia postoperatively (5/16, 31%). One patient had a labial wound complication requiring local wound care. Selected complex RVF can be reliably repaired with good functional outcomes using the Martius flap with anal sphincter reconstruction. Persistent or recurrent fecal incontinence and dyspareunia are common sequela of the underlying perineal injury and repair. No acute or delayed morbidity related to the Martius flap was identified.