Role of the martius procedure in the management of urinary-vaginal fistulas

BACKGROUND: Urinary-vaginal fistula is one of the most common and dreaded complications of obstetric trauma in developing countries. Management of these fistulas is complicated by the presence of substantial urethral loss and the tendency of the repair to break down. STUDY DESIGN: We retrospectively studied 46 patients with urinary-vaginal fistulas operated on in our institution over 5 years. Most of the patients had obstetric trauma as the causative factor. Twelve patients had urethrovaginal and 34 had vesicovaginal fistulas. Of the 12 patients with urethrovaginal fistulas, 8 underwent a Martius procedure and 4 were treated with simple anatomic repair. Of the 34 patients with vesicovaginal fistulas, 13 underwent a Martius procedure and 21 were treated with anatomic repair. Nineteen patients had recurrent fistulas and 17 had multiple fistulas. RESULTS: Only one patient with a urethrovaginal fistula treated with a Martius procedure had recurrence, compared with three of four of the patients having anatomic repair. None of the patients with vesicovaginal fistulas treated with a Martius flap had recurrence, compared with 4 of 21 in the anatomic-repair group (19.05%). Thirteen patients with single fistulas (7 urethrovaginal and 6 vesicovaginal) treated with a Martius procedure healed well without failure, compared with 1 failure among 16 fistulas (1 urethrovaginal and 15 vesicovaginal) in the anatomic-repair group. In the group of patients with multiple fistulas, the Martius flap also showed a definite advantage. Eight patients with multiple fistulas were offered the Martius flap. The procedures were successful in all but one, compared with six failures out of nine treated with anatomic repair. None of the patients having primary treatment with the Martius flap had postoperative recurrence, compared with 3 of 18 having anatomic repair (16.67%). Only 1 of 12 patients with recurrent fistulas undergoing Martius flap repair had failure (8.33%), compared with 4 of 7 undergoing anatomic repair (57.14%). None of the patients treated with the Martius procedure experienced dyspareunia postoperatively, compared with 33.33% of the patients treated with anatomic repair. CONCLUSIONS: The overall success rate was far better and the complication rate (especially incontinence and dyspareunia) was considerably less with the Martius procedure. We recommend the Martius procedure for urethrovaginal and vesicovaginal fistulas, especially those that are recurrent or multiple.