Fistula (vesico-vaginal/urethrovaginal/ano-rectal vaginal)
Iatrogenic bladder injury
Urethral diverticulectomy
Mesh (prolapse/mid-urethral sling) erosion
Urethrolysis
Vaginal/neovaginal reconstruction
Bladder neck augmentation for artificial urinary sphincter
Bladder neck closure
In regard to the repair of UVF, we do favor tissue interposition and reported a 95% anatomical success for closure of UVF due to near exclusive use of tissue interposition in our series. We used mainly autologous fascia as it allows us not only to cover the urethrotomy closure defect but also to prevent secondary SUI associated with intrinsic sphincter defect induced by the UVF. However, in our series, three patients had both a rectus fascia and MLFP interposition with good results. In the context of UVF, a Martius graft may not necessarily be ideal given the bulkiness of the graft and the limited stretching of the vaginal flap to close over it. Nevertheless in the case where vaginal mucosa is deficient for primary closure, a Martius graft with an island of skin can be utilized to breach the defect and allow for tension-free closure [8].
The versatility of the MLFP graft is evident also in the closure of ano- and rectovaginal fistulas [9, 10] as well as in the transvaginal repair of bladder injury during vaginal hysterectomy to prevent fistula formation [11]. Martius flap can be used in transvaginal bladder neck closures as well as urethral diverticulectomy and can also be useful in transvaginal artificial urinary sphincter placement although most authors recommend a retropubic approach for placement of cuffs. Another rare indication is in the post-cystectomy patient with a peritoneo-vaginal fistula [12] or neobladder-vaginal fistula [13]. It can also be used in construction of a neovagina after pelvic exenteration or other rare cases requiring vaginal construction or reconstruction [14]. The most common indication in our practice is as an adjunct to urethrolysis to prevent re-scarring to the back of the pubic symphysis [15–17]. In recent times, the use of synthetic mesh products for prolapse and stress incontinence surgery has seen an escalation in the incidence of mesh erosion and extrusion. Often mesh excision is required and the Martius graft has been utilized with reasonable success as an interposition/buffer layer against fistula formation and/or for the closure of a large defect for healing [18, 19]. Recently, following groin exploration to excise a TOT arm in a woman with additional one-sided vaginal pain and dyspareunia, we used the MLFP as an interposition graft alongside the vaginal wall to create a buffer and decrease pain related with sexual activity on that one side.
Technique
An 8–10 cm long vertical incision is made over the labia majora from the level of the mons pubis down towards the level of the fourchette. This is a typical incision for a high vault vesico-vaginal fistula because the length of the fat pad must be sufficient to reach the vaginal apex. When the procedure is indicated for urethral or bladder neck pathology, the incision can be shorter and may start midway over the labia majora, still extending down to the level of the posterior fourchette. The side, left or right, depends on the location of the pathology being repaired, and at times should be done from the side opposite to where the fat pad will ultimately be placed because of the need for it to cross over.
The labia majora incision is deepened to the level of the labial fat pad. The fat pad can be gently grasped with a Babcock clamp and mobilized on an inferior pedicle providing a postero-inferior blood supply to the graft based on branches from the internal pudendal artery. To facilitate the dissection of the flap, the skin edges can be held retracted by the hooks of a Lonestar retractor . To avoid medial labial skin distortion or retraction after the fat pad harvest has been completed, we recommend leaving some fat medially beneath the labial skin and carrying the fat pad dissection slightly obliquely and away from the inner labial folds. Once a sufficient length has been dissected laterally and medially, the flap is gradually divided superiorly. Large veins can supply the apex of the flap coming from the mons pubis, and they may require careful ligature to avoid retraction and a secondary labial hematoma. Next, the Martius fat pad graft dissection continues by detaching the fat pad posteriorly off the underlying ischiocavernosus and bulbocavernosus muscles, taking care once again to leave a broad base inferiorly to protect the blood supply.
Historically, the MLFP included the bulbocavernosus muscle vascularized by the labial artery, a branch of the internal pudendal artery, as well as the fat pad of the labia majora vascularized by the obturator artery and the internal and external pudendal arteries. Currently, most specialists use the labial fat pad without excising the bulbocavernosus muscle. However, in situations involving a vaginal wall defect after extensive mesh removal or large vesico-vaginal fistulae, the labial fat pad graft can be harvested with a segment of skin to close both defects.
Following complete mobilization of the fat pad, a figure of eight absorbable suture can be placed at the extremity of the flap to help with its tunneling alongside the vaginal wall later on. The fat pad graft can be harvested ahead of any upcoming steps in the repair, which can involve significant bleeding. By doing so, the fat pad is ready for use and can help decreasing the overall blood loss, thus reducing the likelihood for blood transfusion. The fat pad can be wrapped in moist gauze until its use later on. Once the fistula repair or other procedure for which the fat pad graft was selected is completed, a tunnel should be created alongside the lateral vaginal wall towards the destination of the flap. This tunnel is created with long Metzenbaum scissors and/or a ring forceps. The tunnel should be widened to accept at least two fingers in order to prevent compression of the blood supply of the fat pad, which could compromise its survival. The suture at the extremity of the fat pad can then be grasped at the end of a right angle clamp or long Kelly clamp, which can be slid through the pre-established tunnel alongside the vagina. The suture can be retrieved easily on the vaginal side and pulled out to direct the fat pad into its tunnel and ultimately into position over the intended area of coverage. The pedicle graft once passed through the tunnel can be secured in place with a few absorbable sutures over the suture line, which it is intended to protect.
Although the dissection of the tunnel can sometimes provoke bleeding, once the fat pad is in place the bleeding will typically decrease or stop. However, to avoid a secondary labial hematoma, it is recommended to place a labial drain (small Penrose or #7 Jackson-Pratt). The incision is closed in two layers, a running subcutaneous deep absorbable suture over the drain, and then interrupted absorbable sutures on the skin. In case of a secondary infection or hematoma, some of these interrupted sutures at the lower extremity of the skin incision closure can be easily removed to facilitate a drain placement. In the absence of bleeding, swelling, or infection, the labial drain can be removed within 24–48 h postoperatively. A step-by-step video demonstration of our surgical technique has recently been published to aid clinicians in understanding the key points in the operative process [19].
Complications
Hematoma or Seroma
As is the case with most surgical procedures, there is a risk of bleeding and hematoma formation. The fat pad is mobilized on an inferior pedicle based on branches of the internal pudendal vessels as discussed earlier. One of the benefits of this graft as a tissue interposition is its vascularity, but this also contributes to the risk of bleeding and hematoma formation. Thus, maintaining and ensuring achievement of hemostasis at the site of harvest as well as on the pedicle graft itself is of utmost importance in preventing hematoma formation. In addition to meticulous hemostasis at the time of surgery, the use of a drain (Penrose or Jackson-Pratt) postoperatively may also decrease the likelihood of hematoma formation. Although incidence of hematoma is not reported in the literature, Songne and coworkers [10] described a seroma formation in 3 of 14 patients (21%) undergoing repair of anovaginal or rectovaginal fistulas with Martius interposition. A recent abstract by Hussain and coworkers reported one (2%) labial hematoma in a series of 55 women with MLFP performed for various indications [20].
In our experience, maintaining careful hemostasis at the site of harvest as well as on the pedicle graft itself is of utmost importance in preventing hematoma formation. In addition, the use of a drain (Penrose or Jackson-Pratt) postoperatively may also decrease the likelihood of hematoma or seroma formation. Typically, seromas and hematomas when they occur will resolve on their own over time without any intervention. Recently, we published our long-term outcomes (mean follow-up duration of 7 years) in 97 women who had MLFP and no hematoma or seroma was encountered in our series [21].
Infection
Although the incidence of wound infection for a Martius fat pad graft is not well studied or reported, the risk of such a complication appears to be relatively small. McNevin and coworkers [9] reported one (6%) superficial labial wound breakdown among 16 patients undergoing repair of complex rectovaginal fistulas with the use of Martius as tissue interposition whereas Songne and coworkers [10] reported no wound infections in their retrospective series of 14 patients. Just as with hematoma and seroma, the use of a drain postoperatively may decrease the risk of infection as may appropriate perioperative antibiotic usage. This has been a very rare occurrence in our practice over the past 25 years. Yeast infection can also easily develop in the groin or over the incision and should be treated by the use of antifungal ointment or oral medications. This can sometimes be prevented by the preoperative treatment of infections present prior to surgery and by keeping the groin and perineum clean and dry postoperatively. However, if either becomes infected as would be indicated by erythema surrounding and/or purulent drainage from the incision, then prompt drainage is indicated.
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