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

Background: Urinary-vaginal fistula is one of the most common and dreaded c omplications of obstetric trauma in developing countries. Management of the se 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 f istulas operated on in our institution over 5 years. Most of the patients h ad obstetric trauma as the causative factor. Twelve patients had urethrovag inal and 34 had vesicovaginal fistulas. Of the 12 patients with urethrovagi nal fistulas, 8 underwent a Martius procedure and 4 were treated with simpl e anatomic repair. Of the 34 patients with vesicovaginal fistulas, 13 under went 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 Mart ius procedure had recurrence, compared with three of four of the patients h aving anatomic repair. None of the patients with vesicovaginal fistulas tre ated with a Martius flap had recurrence, compared with 4 of 21 in the anato mic-repair group (19.05%), Thirteen patients with single fistulas (7 urethr ovaginal and 6 vesicovaginal) treated with a Martius procedure healed well without failure, compared with 1 failure among 16 fistulas (1 urethrovagina l and 15 vesicovaginal) in the anatomic-repair group. In the group of patie nts with multiple fistulas, the Martius flap also showed a definite advanta ge. Eight patients with multiple fistulas were offered the Martius flap. Th e 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 recurr ent fistulas undergoing Martius flap repair had failure (8.33%), compared w ith 4 of 7 undergoing anatomic repair (57.14%). None of the patients treate d with the Martius procedure experienced dyspareunia postoperatively, compa red with 33.33% of the patients treated with anatomic repair. Conclusions: The overall success rate was far better and the complication r ate (especially incontinence and dyspareunia) was considerably less with th e Martius procedure. We recommend the Martius procedure for urethrovaginal and vesicovaginal fistulas, especially those that are recurrent or multiple . (J Am Cell Surg 2000;191:253-263. (C) 2000 by the American College of Sur geons).