Martius flap like approach for neobladder -vaginal fisulae after orthotopic urinary diversion in woman.
Vescico-vaginal fistulae (VVF) is uncommon and difficult pathology to manage especially because they occours in patients with previously surgery (trans abdominal hysterectomy 70%, trans vaginal hysterectomy 20%), radiotherapy exposition (6/10%) or in case of pelvic floor tissue ischemia (long labor time 10%) (1,2,3,4,5). Another clinic condition that can be at risk for vaginal fistula is in case of neoblabber replacement after radical cystectomy and occurring in 0–10% (6,7,8,9,10). Several risk factors have been identified in poorly vascularized tissue between the urethra neobladder anastomosis and anterior vaginal wall on the suture line proximity and in the damage to the anterior vaginal wall during dissection The technique that we are going to describe was introduced by Dr Heinrich Martius in 1928 in African women with vescico-urethral-fistula caused of a long labor time after recurrence with poor functional outcomes. This kind of flap has been used for urogyncological fistulae and less frequently for rectovaginal fistulae (11). Generally, the surgical approach, depending on the complexity of the cause and the localization of the fistulae. There are various techniques repair that can be considered like gracile muscle flaps, trans abdominal omentum flap, transperineal and transvaginal approaches or fistula plugs (12,13) and can be performed opening, lapharoscopy or Robot assisted. Healthy tissue transfer is important more that the tecnique for a good outcome of complex fistulae especially for clinical patients history. For low fistulae, when rectal, perineal or vaginal approach is planned, Martius flap become an excellent choice being in close proximity of the operation field (14).
Materials and Methods
We report a small collection of 2 patients with VVF after orthotopic urinary diversion. The first one is a patient 66 years old who received the Martius flap after previously transvaginal approach for anterior vaginal wall fistula with neo-bladder urethra anastomosis with a double wall layer repair. The recurrence occurred after 3 months and in the same side and the fistula size was 1.5cm. The second is a patient 62 years old received a Martius flap like first step for laterally vagina fistula wall with neo-bladder urethral anastomosis with size of 1cm. In both cases anterior vagina wall was sacrificed during radical open cystectomy and the posterior wall was folded anteriorly and anastomosed to the margin of vagina resection.
The patients independently of previously transvaginal surgical approach were dry after removal catheter in 15th day. A cystoscopy and cystography performed after two months were without evidence of recurrence. At an average of 20.5 months (24, 17 months) both the patient are dry.
We think that anterior approach of the neo-bladder vagina fistula using the Martius flap represents the less invasive and feasible technique that can be employed with minimally morbidity especially compared to gracile muscle flap or abdominal approach. We suggest this technique before to plane ad abdominal approach. Particular indication can be considered in all patients with poor outcome or actinic tissue damage because the bulbocavernosus muscle provides with a good drainage of the local secretion and in same time supplied an appropriate blood and lymphatic support .
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