Martius' labial fat pad interposition and its modification in complex lower urinary fistulae.SV Punekar, DN Buch, AB Soni, G Swami, SR Rao, JS Kinne, SS Karhadkar
Department of Urology, Seth G. S. Medical College, Parel, Mumbai, India., India
OBJECTIVE: To assess the results of Martius' labial fat pad interposition and its modification using skin island in the repair of giant and recurrent vesicovaginal and urethrovaginal fistulae. PATIENTS AND METHODS: Fifteen patients of urethrovaginal and vesicovaginal fistulae underwent Martius' labial fat pad interposition and its skin island modification during 1996 to 1999. Ten of these were recurrent (66%) and five were giant fistulae (34%) i.e. more than five cms. RESULTS: Results were very gratifying with a successful repair in 14 patients (93%). Two patients had transient, low-grade stress incontinence, which did not need any additional procedure. In one patient, there was failure of repair, which was later successfully repaired using fat pad from opposite labia. CONCLUSION: Martius' fat pad interposition provides vascularity and surface for epithelialisation and also prevents overlapping of vesical/urethral and vaginal suture lines. Martius' repair has good results with low morbidity in the treatment of giant and recurrent urethrovaginal and vesicovaginal fistulae.
Keywords: Female, Human, Recurrence, Surgical Flaps, Urethral Diseases, surgery,Urinary Fistula, surgery,Vesicovaginal Fistula, surgery,
History of vesicovaginal fistulae dates from antiquity. Over five million women are affected each year according to WHO estimates. This is associated with significant decrease in quality of life for the unfortunate patient. The obstetric injury is a rare cause of urinary fistula in developed countries. However it still remains the commonest cause of fistulae in developing countries.
Obstetric fistulae result from pressure necrosis and hence have poor local tissue vascularity and at times tend to be large in size. In recurrent fistulae there is scarring and poor vascularity. Therefore vascularised tissue interposition becomes mandatory in these types of fistulae. The omentum., peritoneum, labial fat pad (Martius'), Gracilis muscle and bowel have been used as tissue interposition in reconstruction of such fistulae.
We present results with Martius' labial fat pad interposition and skin island flap as its modification in the management of giant and recurrent vesicovaginal and urethrovaginal fistulae in 15 patients.
Fifteen patients with low vesicovaginal and urethrovaginal fistulae, in the age range of 18 to 40 years, were treated in the teaching department of urology between 1996 and 1999. All the patients presented with continuous leakage of urine.
Twelve of these (80%) had history of obstructed labour and obstetric manipulations and three (20%) had fistula following hysterectomy for gynaecological causes [Table - 1].
Ten cases (66%) had prior failed repairs done elsewhere. Seven of these were transabdominal repairs and three were transvaginal repairs.
After a detailed history and clinical examination, vaginal examination was done. The number, size, and location of fistulae, oedema or inflammation of surrounding vaginal mucosa, pliability of anterior vaginal wall and adequacy of introitus were assessed
Urinalysis and serum biochemistry were done and this was followed by intravenous urography to rule out concomitant ureteral injury in all patients.
Cystourethroscopy revealed that all patients had solitary fistula Six patients had fistula less than 2 cm and nine patients had fistula of more than 2 cms in size. Five patients had giant fistula i.e. size more than 5 cms. The fistula was urethrovaginal in three, trigonal in ten, and two had involvement of trigone and proximal urethra. All fistulae were at least 0.5 cm away from the ureteric orifice [Table - 2].
Timing of surgery was decided depending upon the local tissue condition on serial examination mid this varied from eight weeks to six months. Preoperative antibiotics were given on the morning of surgery [Table - 3].
Under regional or general anaesthesia, patient was placed in low lithotomy position and both abdomen and perineum were prepared. Labia were sutured to inner side of thigh. Ureteric catheterization was done whenever fistula was within 0.5 - 1 cm of ureteric orifice. Anterior vaginal flap was raised with wide base at bladder neck and the fistula was sharply circumscribed with a circumlesional incision. Margins of fistula were freed from any scar tissue to facilitate closure. Fistula was closed with running 4-0 absorbable polyglycolic sutures.
Retraction suture from one labia was removed. Vertical incision was made over the labia major and labial fat was exposed. Fat pad was mobilised starting anteriorly. The pudendal vascular supply entering the fat pad posteriorly was carefully preserved as described by Martius.
For high trigonal defects, where the flap had to be taken deep inside, it was based on superior supply from external pudendal artery. Next, a tunnel was created sublabially and transferred through the tunnel into vagina. The flap was secured over die sutured fistula site with absorbable sutures. Vaginal flap was closed over the repair with 3-0 absorbable suture. Labial incision was closed with subcuticular sutures. Betadine soaked light vaginal gauze was kept as dressing.
In four cases, tensionless approximation was not possible due to large size of fistulae. A modified Martius' flap with skin island was used to close the defect as described by Bissada. Skin island of required size was marked [Figure - 1]. The skin island with pedicle was elevated from superior aspect of labia major [Figure - 2]. The skin island with the pedicle was transferred sublabially into vagina and sutured to the defect in the vaginal wall [Figure - 3].
Urethral and suprapubic catheters were kept for 7-10 days. Antibiotics were continued postoperatively. Vaginal gauze was removed the morning after surgery. On discharge, patients were instructed to avoid coitus for three months. Follow-up was done at three, six and 12 months.
Fifteen patients underwent Martius' flap interposition, including four patients with a overlying skin island.
Results were very gratifying with successful repair in 14 patients (93%). In one patient, persistent fistula was noticed on eighth post-operative day. She underwent a successful repair after three months using Martius' flap from the opposite labia.
Two patients with involvement of trigone and proximal urethra had transient, low-grade stress incontinence for three to six months. No additional surgery was required and both were dry later. Two, patients had pregnancy and lower segment caesarean section was done to deliver babies.
Various surgeons have approached fistula reconstruction in different ways. Some of the hotly debated issues in the management of vesicovaginal fistula (VVF) are timing and route of surgery. No gold standard can be drawn for all situations. Every patient merits individual consideration. The optimal time of surgery is when tissue is free of inflammation and pliable enough to hold sutures. The route of surgery, abdominal or vaginal, is decided by the preference and expertise of the operating surgeon. Tissue interposition in the repair of post-radiation, giant or recurrent fistula is being extensively done. Tissue interposition is justified since there is often insufficient tissue for second layer of closure. Peritoneum, labial fat pad, omentum, Gracilis myocutaneous or myofascial flap and gluteal skin rotational flaps have been used to reinforce the repair.
Martius' flap provides a well vascularised tissue and a surface for epithelialisation, while it prevents overlapping of urethral and vaginal suture lines. Martius drew attention to the possibility of repairing fistulae earlier, since they noted that interposed fresh tissue had the ability to arrest the ischaemic process in the surrounding tissue by the growth of new capillaries into the ischaemic area. It has also been suggested that this graft facilitates re-establishment of continence in patients with urethrovaginal fistula. But, various authors have mentioned persistence of stress incontinence even after labial fat pad interposition with an of 20-40 percent,. Birkhoff et al believe that fat pad interposition was a significant factor in the success of the procedure. In our series, two cases (14%) of urethrovaginal fistula had incontinence for three months post- operatively. This was totally cured without any need for additional surgical intervention. This could perhaps be explained by the theory that urethral wall gets support and pliability with Martius' pad of fat in sutured position.
As shown in [Table - 4] the success rate of Martius' flap of fat varies from 87% to 100%.
In comparing the results of Martius' flap interposition, it is observed that four out of six series have 100% success rate. However, Keetal et al had 87.5% success in their 24 cases which may he due to large number of recurrent fistulae. The present series has 93% success in 15 cases, where ten patients (66%) had recurrent fistula and therefore these results can be considered favourable in comparison.
Over the centuries the scenario has changed from considering fistula as an entity beyond repair to 100% success rate towards the end of second millennium. The cause of fistula has also changed from child birth injuries to post irradiation or gynaecological and surgical procedures in major part of world. One cannot say that they can be completely prevented and therefore the management strategy must be taught, learnt and practised as long as these fistulae exist. We believe that interposition of labial pad of fat helps improve the success rate of repair in giant and recurrent vesicovaginal fistulae.
We wish to thank- Dr. R G Shirahatti, the Dean of Seth GS Medical College and King Edward Memorial Hospital, Mumbai for permission and Mrs. Namarata P. Parab for the secretarial help.
[Figure - 1], [Figure - 2], [Figure - 3][Table - 1], [Table - 2], [Table - 3], [Table - 4]